St. Raymond's Society Community Client Application 2024

Your name *

Last name

Email address *

Address

HomeWorkOther

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone Number

Birthdate

SSN:

Required for background check

Are your receiving services from another agency?

Yes

No

APPLICANT

DEMOGRAPHICS

Living Arrangements:

Homeless

Shelter

Maternity Home

Living with mother

Living with father

Living with parents

Living with husband

Living with boyfriend

Live alone or with child(ren)

Living with relative(s)

Other

Ethnicity:

African American

Asian

East Indian

Hispanic/ Latin American

Native American

Caucasian

Pacific Islander

Middle Eastern

Other

Relationship Status:

Single

Married

Divorced

Separated

In a relationship

Widowed

Veteran

Yes

No

Have you ever been in foster care?

Yes

No

Highschool Diploma:

Yes

No

GED?

Yes

No

Last grade or level of school completed?

Student?

Yes

No

School attending?

Divers License?

Yes

No

Own Vehicle?

Yes

No

Employed?

Yes

No

Place of employment:

Position:

Part-time

Full-time

How long have you been employed here?

Additional Assistance:

Child support

TANF / SSI

Medicaid

WIC

SNAPS (food stamps)

HUD

Childcare assistance

Other

Religious preference?

Church attending?

PREGNANCY/PARENTING

Pregnant?

Yes

No

If pregnant, due date?

Doctor?

Baby's father's name, city and state of residence:

Describe your current relationship with him:

Other children:

Name:

Birthdate:

Male

Female

Custody:

Yes

No

Shared

If no, who is with the child?

Child's father's name, city and state of residence:

Describe your relationship with him:

Receiving child support?

Yes

No

If yes, how much per month?

Paying child support?

Yes

No

If yes, how much per month?

Name:

Birthdate:

Male

Female

Custody:

Yes

No

Shared

If no, who is the child with?

Child's father's name, city and state of residence:

Describe your relationship with him:

Receiving child support?

Yes

No

If yes, how much per month?

Paying child support?

Yes

No

If yes, how much per month?

HEALTH HISTORY

Do you have any current or chronic physical health issues?

Yes

No

If yes, please describe:

List any medications you are currently taking:

Have you ever been diagnosed with a mental illness?

Yes

No

If yes, what was the diagnosis and when was the diagnosis given?

Are you currently receiving treatment?

Yes

No

If yes, describe treatment including all medications:

Doctor(s) overseeing your treatment:

Are you currently (recently) or have you ever been a victim of any type of abuse?

Yes

No

If yes, please provide any details that would be important in determining qualifications for the program.

LEGAL HISTORY

Have you ever been convicted of a misdemeanor?

Yes

No

If yes, describe:

Have you ever been convicted of a felony?

Yes

No

If yes, describe:

Are you currently (recently) or have you ever consumed alcohol?

Yes

No

How often:

Daily

Weekly

Monthly

Rarely

ADDICTION/SUBSTANCE ABUSE HISTORY

Do you currently smoke?

Yes

No

If yes, how many per day?

Are you currently (recently) or have you ever used illegal drugs?

Yes

No

Age when began:

What is/was your drug(s) of choice?

How long ago?

Recently:

Yes

How often?

Daily

Weekly

Monthly

Rarely

Have you ever been in an addiction treatment program?

Yes

No

How many programs?

Have you ever successfully completed an addiction treatment program?

Yes

No

What was the program called?

Where was the program located?

When did you enter the program?

When did you complete the program?

How long have you been "clean" or drug free?

When was your last drug test?

What type of test?

Describe the services/support that you are requesting from St. Raymond’s Society and the reasons that you are making the request:

APPLICANT'S AGREEMENT

I hereby attest and agree that all of the information I have provided here-in is complete and true to the best of my knowledge.

I understand that false or incomplete information can result in my application being denied, or affect my consideration for future services.

I understand that, in order for this application to be approved, I will be required to speak and/or meet with St. Raymond’s Society staff members on one or more occasions.

I hereby grant the staff of the St. Raymond’s Society permission to conduct a background check and to contact any person or agency listed on this application to verify information or discuss my well-being.

Applicants Signature:

MISSION:

Partnering with new and expectant mothers to build a thriving future for themselves and their families.

Date:

Please allow 24-48 hours after application has been received for staff to review. If there has been no contact after 48 hours, please feel free to contact us:

(573) 777-1498
www.srshelp.org

Submit

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