Transitional Apartment Application Form

Transitional Apartment Application Form

A Transitional Living Center

  • The Kelley House: 202 E. Nebraska, Greensburg, Kansas 67054
  • The Julius House: 501 S. Pine Street, Greensburg, Kansas 60754

A service of the Iroquois Center for Human Development, Inc.610 E. Grant Avenue, Greensburg, Kansas 67054620-723-2272

 

Personal Information:

Name:_____________________________

SSN:_____________________

Current Address:______________________________________________________

Current Phone Number:_______________________ Age:_______

Date of Birth:________________  Sex: M / F

Current county of residence:_______________________

County of responsibility:__________________________

Financial Information: (List the monthly amounts for the following income sources)

SSI $_______    SSDI $________   Other income $_________ VA benefits $__________

Do you have Medicare? _____  Medicaid?_____ Medikan?_______

Please send copies of insurance card(s) with this application.  Do you have private

insurance? (list the provider)

____________________________________________________

Do you have a guardian? (list name, phone number, and address)

__________________________________________________________

__________________________________________________________

Do you have a payee? (list name, phone number and address)

__________________________________________________________

__________________________________________________________

Do you have a conservator? (list name, phone number, and address)

__________________________________________________________

__________________________________________________________

 

Referral Source:

Person making referral:____________________ Phone Number:________________

Relationship to person referred:________________________________

Community Mental Health Center:______________________________

CMHC case manager or contact person:__________________________

Phone number:____________________

Reason for referral:______________________________________________________

 

Family/Contact Information:

List family member you want contacted in case of an emergency: _______________________________ Relationship:__________________

Phone number:___________________ Address:______________________________________________________

List non-family member person you want contacted in case of an emergency:________________________ Relationship:______________

Phone number:______________________

Address:_____________________________________________________

 

Medical Information:

Medical doctor:___________________________

Phone number____________________________

Address:_________________________________

Psychiatrist:_____________________________

Phone number:__________________________

Address:________________________________

 

List other doctors seen within the past year (dentist, optometrist, etc…)

Doctor:____________________________ Seen for:__________________

Phone number:__________________ Address:_____________________________________________________

Doctor:___________________________ Seen for:___________________

Phone number:_________________

Address:_____________________________________________________

 

List all medications you currently take, including dosage and frequency:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

 

Name of pharmacy:____________________________________________

Phone number:__________________________________

Address:_____________________________________________________

 

List any allergies or medical conditions we should be aware of: ____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

 

List all medical and psychiatric hospitalizations within the past year:

 

Hospital: ____________________________________________________

Reason for admission:_________________________________________

Length of stay:_______________________________________________

Hospital:____________________________________________________

Reason for admission:_________________________________________

Length of stay:_______________________________________________

Hospital:____________________________________________________

Reason for admission:_________________________________________

Length of stay:_______________________________________________

(List additional hospitalizations on backside of form)

 

Other Information: What skills do you wish to learn and what goals do you hope to accomplish by living at the Julius House?

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

 

When did you last live independently in the community and for how long? _________________________________________________________

**You may be asked to sign a release of information form so that the Iroquois Center for Human Development may contact any of the individuals listed on this form.

**After this form is completed and the requested records are received, the referral will be processed and an interview will be arranged with the Housing Coordinator.   If you are eligible to live at the Julius House and there is an opening, the Housing Coordinator will help you with further plans for admission.  If you are eligible but there is not an opening, your name will be put on a wait list.

 

 

The information provided in this application is complete and accurate to the best of my knowledge.  I understand the process for admission after I submit this application form.  ____________________________     __________________________          (Person referred)                                 (Date of Application)

____________________________     __________________________

(Witness)                                                  (Date)