Family Application Form

Date

Personal Information

Adult 1 Name *

First

Adult 1 Name *

Last

Adult 1 Date of Birth *

Adult 1 Phone Number *

Adult 1 Email *

Adult 1 Social Security # *

Adult 2 Name

First

Adult 2 Name

Last

Adult 2 Date of Birth

Adult 2 Phone Number

Adult 2 Email Address

Adult 2 Social Security #

Marital Status * Marital Status

Child 1 in Household *

First and Last

Child 1 Date of Birth *

Month, Day and Year

Name of School/Daycare *

Cost of Daycare per Week

Cost per child

Child 2 Name

First and Last

Child 2 Date of Birth

Month, Day, and Year

Name of School/Daycare

Cost of Daycare per Week

cost per child

Child 3 Name

First and Last

Child 3 Date of Birth

Name of School/Daycare

Cost of Daycare per Week

cost per child

Child 4 Name

First and Last

Date of Birth

Month, Day and Year

Name of School/Daycare

Cost of Daycare per Week

Cost per child

Child 5 Name

First and Last

Date of Birth

Month, Day, and Year

Name of School/Daycare

Cost of Daycare per Week

Cost per child

Child 6 Name

First and Last

Date of Birth

Month, Day and Year

Name of School/Daycare

Cost of Daycare per Week

Cost per child

Are you currently pregnant or is there a possibility that you are? *

When is your due date?

Are all of your children currently in your care? *

Please explain your relationship to the children in your household. *

Do any of your children have any mental, emotional, and/or physical problems? *

Please explain. *

If dirovced, How long have you been divorced? Do they have custody rights? *

If single or divorced, Where is dad/mom of children? Does he have contact or custody? Do you receive child support? If so, how much? *

If your children have any disabilities are they being properly treated? *

Housing

Family's Current Address

City

State/Province

Zip/Postal

Current Living Situation *

Where were you living prior to being homeless and what events led up to you being homeless? *

Please explain your current living situation *

i.e. Behind on rent, unsafe living situation, possible eviction

If homeless, How long have you been homeless? *

If currently in housing, When is your lease up? *

Rent or Mortgage per Month

How much is your monthly rent or mortgage payment?/Are you behind?/If so, how far behind?

Is there anyone living in the home with you other than the people listed on this application? *

Please explain. *

Who, Relationship to you, how long have you lived together? etc.

Evictions *

When? Where? How Much?

Do you receive housing assistance? *

Please Explain *

How much? Who from?

Do you have any pets? *

Yes

No

Please list the type of animal, weight, and if it is an ESA registered animal. *

Employment

Which best describes the educational level of Adult 1? *

Does Adult 1 wish to go back to school? *

Yes

No

Is Adult 1 employed? *

Please list the following: Employer/Address/Phone Number/Wage/How long have you been employeed at this job

Please explain how long you have been unemployed and why? *

What was your last job? How long were you at that job and why did you lose it? *

Which best describes the educational level of Adult 2?

Does Adult 2 wish to go back to school? *

Yes

No

Is Adult 2 employed?

Please list the following: Employer/Address/Phone Number/Wage/How long have you been employeed at this job

Please explain how long you have been unemployed and why? *

What was your last job? How long were you at that job and why did you lose it? *

Transportation

Do you have a car? * Do you have a car?

Vehicle Year

Make

Model

License Plate #

Auto Insurance Carrier

Cost Per Month

Do you have a car loan?

Details

Cost per month/total loan amount/past due/other info

Medical Background

Does Adult 1 have any mental, emotional, and/or physical health problems? *

Please explain.

List any medications for Adult 1.

Is Adult 1 under a doctor's care? *

Please explain. When were you diagnosed? Are you being treated for your diagnosis and how long have you been on treatment?

Has Adult 1 ever experienced physical, sexual, or emotional abuse? *

Please explain. When did it occur? Have you seeked proper treatment? Where?

Has Adult 1 been involved in counseling or therapy? *

Please explain. Where and for how long?

If Adult 1 is not currently in counseling, are they willing? *

Does Adult 2 have any mental, emotional, and/or physical health problems?

Please explain.

List any medications for Adult 2.

Is Adult 2 under a doctor's care?

Please explain. When were you diagnosed? Are you being treated for your diagnosis and how long have you been on treatment?

Has Adult 2 ever experienced physical, sexual, or emotional abuse?

Please explain. When did it occur? Have you seeked proper treatment? Where?

Has Adult 2 been involved in counseling or therapy?

Please explain. Where and for how long?

If Adult 2 is not currently in counseling, are they willing?

Benefits and Finances

Do you receive benefits? *

Yes

No

Does Adult 1 have health insurance?

Adult 1 Carrier

Does Adult 2 have health insurance?

Adult 2 Carrier

How much you are receiving from each benefit

Total approximate monthly income *

Include wages and child support

Where are all of the places you receive monthly income from? *

Monthly Grocery Expense *

Monthly Utilities *

Credit Card Debt & Monthly Expense *

Monthly Cell Phone Expense *

Other Expenses *

Please Describe

Total Debts Owed

Please describe what and how much is owed for each item.

Has your family or any member of your family previously had any type of assistance from another organization / group / counseling? *

Yes

No

Who assisted, and was it helpful?

What other organizations have you received help from? *

If you are accepted into our program and needing financial assistance, we will ask for you to take part in a financial program that is linked to your bank account to help with budgeting. Are you willing to comply with this? *

Yes

No

Additional Information

If there are charges or previous arrests, please explain what happened. *

Have you or any other extended family members or relatives been in prison, arrested, charged or have or had pending or dropped charges with any tickets, crimes, misdemeanors, felonies, or involved in any other legal matters that we should know about? *

Yes

No

Describe the Charges

Please explain why CPS was involved with your family and the current status of the CPS case. *

Is their current or past CPS involvement with your family? *

Yes

No

Please explain. *

Are you at risk of CPS involvement, or having your kids removed from your care? *

Yes

No

Please explain. *

Please provide any other useful information that was not included in this application.

Needs

If there were 3 things you could have right now to help you be self sufficient, what would those be? *

What services do you believe you need to achieve and sustain self-sufficiency? *

What are the main problems that you or your family are dealing with at this time?

What is your faith background? *

Grace Like Rain commits to serving families in crisis through the use of professionals and volunteers willing to extend God’s grace and unending love. If approved for our program, a volunteer family coach and Family Case Manager are assigned to help you work towards accomplishing your family's established goals. A plan will be created with achievable short and long term goals that will help you work towards stability and self-sufficiency. The coach will motivate, support and walk alongside the parents helping them work towards positive life changes. Counseling, parenting classes, budgeting classes, government aid, housing, employment, education, life skills, Bible studies, and support groups are among many possible directions the coach will guide the family towards. Please explain why you would be a good fit for our ministry. *

Please explain why you would be a good fit for our ministry.

Personal Information

Housing

Employment

Transportation

Medical Background

Benefits and Finances

Additional Information

Needs

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