Screening Application – Interfaith Family Services

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Interfaith Screening Application

PLEASE fill out the form completely. Place “N/A” in any section that does not apply. Incomplete applications will not be given further consideration.

Intake Information

Today's Date (Fecha de hoy)

Preferred Language (idioma preferido)

EnglishSpanishOther

Which program are you applying for? (¿qué programa está solicitando).

How did you hear about us? (¿cómo se enteró de nosotros)

If other, please list (En caso contrario, por favor enumere)

Have you ever resided at our properties or participated in our programs? (¿Alguna vez ha participado en nuestro programa)

Current Living Situation (situación actual de la vida)

Applicant Information

First Name

Last Name

Date of Birth (Fecha de nacimiento)

Social Security Number (número de seguro social)

Phone

Address Line 1

Address Line 2

City

State

Postal Code

County

Race (Carrera)

Relationship Status

Do you have a driver's License or state ID?

Highest level of education COMPLETED (nivel más alto de educación completada):

Are you pregnant?¿Está embarazada

Do you have children under the age 18 in your legal custody? (¿Tiene niños menores de 18 años bajo su custodia legal)

If yes, how many children? En caso afirmativo, ¿cuántos niños?

Please list child(ren) name & age:(Por favor, indique el nombre y las edades de los niños):

Co-Applicant Information

First Name

Last Name

Date of Birth (Fecha de nacimiento)

Social Security Number (número de seguro social)

Phone

Race (Carrera)

Relationship Status

Employment Status

Rental History

Do you have at least 6 consecutive months of rental history in the past 3 years? ¿Tiene al menos 6 meses consecutivos de historia aquiler en los últimos 3 años?

Employment History

Employment Status

Do you have at least 6 consecutive months of employment history in the past 3 years? ¿Tiene al menos 6 meses consecutivos de historia laboral en los últimos 3 años?

Criminal/Alcohol/Drug History

Do you have a history of drug or alcohol abuse? (¿Tiene antecedentes de abuso de drogas o alcohol?)

Does your co-applicant drug or alcohol abuse? (¿Tiene antecedentes de abuso de drogas o alcohol?)

Do you have a criminal background? (¿Tiene antecedentes penales?)

If yes, what was the charge? (En caso afirmativo, ¿cuál fue el cargo?)

Have you ever been convicted of a sexual offense or do you currently have sexual charges pending? (¿Alguna vez ha sido condenado por un delito sexual o actualmente tiene cargos sexuales pendientes?)

Do you have a history of mental health or illness? (¿Tienes antecedentes de salud mental o enfermedad?)

If yes, what was the diagnosis? Does it prevent you from working? (En caso afirmativo, ¿cuál fue el diagnóstico? ¿Te impide trabajar?)

I HEREBY CERTIFY that the information provided in this form is complete, true, and correct to the best of my knowledge.

Signature (Firma)

Contact Information

Interfaith Screening Application

PLEASE fill out the form completely. Place “N/A” in any section that does not apply. Incomplete applications will not be given further consideration.

Intake Information

Today’s Date (Fecha de hoy)

Preferred Language (idioma preferido)

EnglishSpanishOther

Which program are you applying for? (¿qué programa está solicitando).

How did you hear about us? (¿cómo se enteró de nosotros)

If other, please list (En caso contrario, por favor enumere)

Have you ever resided at our properties or participated in our programs? (¿Alguna vez ha participado en nuestro programa)

Current Living Situation (situación actual de la vida)

Applicant Information

First Name

Last Name

Date of Birth (Fecha de nacimiento)

Social Security Number (número de seguro social)

Phone

Address Line 1

Address Line 2

City

State

Postal Code

County

Race (Carrera)

Relationship Status

Do you have a driver’s License or state ID?