Confidential Dream Program Application

Date

Name*

First Last

Other names used (if any)

Date of Birth

Children

1. Name

First Last

1. Date of Birth

1. Gender

2. Name

First Last

2. Date of Birth

2. Gender

3. Name

First Last

3. Date of Birth

3. Gender

Contact Info

Phone*

Is it OK to leave a message?

Yes
No

Email address

Is it OK to send an email?

Yes
No

Current address/Last place of residence

Street Address Address Line 2 City State ZIP Code

How long have you been there?

How did you hear about the Dream Program?

Name of person you heard about the program from (if applicable)

First Last

Phone number of person you heard about the program from (if applicable)

Do you have a caseworker/advisor/counselor that Dream Program may contact?

Yes
No

Caseworker Name

First Last

Caseworker Phone

Hours

Housing History

Last permanent address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long at this address?

When?

Rent amount

Reason for leaving?

Have you ever been evicted?

Yes
No

If yes, explain:

Personal/Health Information

Are you pregnant?

Yes
No

If yes, due date:

Do you or any members of your household have medical problems or disabilities that require special services?

Yes
No

If yes, explain:

Are you or any members of your household on any medication?

Yes
No

If yes, explain:

Who is your primary care physician?

Do you have healthcare insurance?

Yes
No

If yes, name of insurance provider and family members covered:

Do you have any concerns of substance abuse or has anyone around you expressed concern?

Yes
No

Have you ever been in a recovery program?

Yes
No

If yes, explain:

When?

Have you or any members of your household been in jail or in prison?

Yes
No

If yes, explain:

Mental Health

Do you have any current mental health concerns or diagnoses?

Yes
No

If yes, explain:

Have you or any family members been hospitalized for a psychiatric/mental health issue?

Yes
No

If yes, explain:

Have you ever been treated for mental health concerns or seen a therapist, counselor or medical professional?

Yes
No

If yes, explain:

Have you ever been in a residential or day treatment program?

Yes
No

If yes, explain:

Have you experienced any significant life changes in the last year?

Choose all that apply.

If any of above/other, explain:

Are you currently having any thoughts of suicide or self-harm?

Yes
No

Have you ever attempted to harm self or take own life?

No
Yes, less than 5 years ago
Yes, more than 5 years ago

Are you currently having thoughts about harming someone else?

Yes
No

Child Custody

Are all of your children living with you now?

Yes
No

If no, explain:

Do you have shared custody of your child with his/her father/mother?

Yes
No

Describe your custody arrangement:

Legal/Financial Issues

Do you have any current legal issues such as:

Choose all that apply.

If any of above/other, explain:

Are you experiencing any financial challenges?

Yes
No

If yes, explain:

Adult Relationships

Has your current or former partner ever been abusive?

Yes
No

If yes, where does he/she live?

If yes, check all abuses that apply

Choose all that apply.

How recently did the abuse occur?

Please include any more details you’d like us to know

Have you ever been in a battered women’s shelter?

Yes
No

If yes, where?

If yes, when?

If yes, Your counselor’s name

First Last

If yes, your cousenlors phone:

Educational History

What is the highest level of education you have completed?

If you have a degree, highest degree earned:

Job History

Present job/position

Employer

Employment start date:

Gross monthly income $

Employer

Previous job/position

Dates of employment

Start Date and End Date

Gross monthly income $

Why did you leave?

What is the longest time you have worked at one job?

Include Years and Months

Dates of employment

Start Date and End Date

Gross monthly income $

Why did you leave?

Total Current Income Per Month

Total Dollar amount: $

Job 1 amount: $

Job 2 amount: $

Job 3 amount: $

CalWorks/TANF amount: $

SSI amount: $

Social Security amount: $

Spousal support amount: $

Pensions amount: $

Child Support amount: $

CalFRESH amount: $

Other amount: $

Are your wages being garnished?

Yes
No

If yes, explain:

What other deductions are made from your pay (debt repayment, child support)?

Have you ever filed bankruptcy?

Yes
No

If yes, explain:

Confidential Dream Program Application

Children

Contact Info

Housing History

Personal/Health Information

Mental Health

Child Custody

Legal/Financial Issues

Adult Relationships

Educational History

Job History

Total Current Income Per Month

Other Questions

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