Emergency Housing Packet

Intake Form Date

General Information

First Name

Last Name

Age & DOB

State ID/Driver License #

Phone *

Last Address

Place of Birth (city, state, county)

Emergency Contact Info

Full Name

Relationship

Phone Number(s)

Address

Family/Social Relationships

Next of Kin

Phone Number

City

Address

State

I have family/friends to help me or support me?

Do you have legal custody of your children

Minor children living with you? Include: Name, Age, Birthdates, Gender, School Attending

Military and Citizenship

U.S. Citizen

Permanent Resident Alien

Veteran

If Yes, What Branch?

Discharge

Monthly Financial Income Information

Do you have income

Other than Employment (monthly) $

SSI/SSD $

Cash Aide $

Disability $

Food Stamps $

Child Support $

General Relief $

Other $

Do you have a Job?

Where do you work?

What city?

How many hours do you work?

When are your paydays?

How are you paid?

Pay Cycle?

Financial Obligations

Car Payment $

Car Ins$

Gas$

Cell Phone $

Child Support $

Court Cost/Fees $

Storage $

Meds $

Other $

Total income $

Total obligations $

Balance $

Do you have:

Bank Name and detail if it is a Savings, Checking or Both

Medical Information

What physical or medical issues do you have?

Do you have a physical disability?

If so, what is your disability?

Physical limitations with stairs?

Physical limitations with a top bunk?

Do you have a Mental Health Diagnosis?

If Yes, what is is?

Medications for Mental Health

Therapist, psychologist, Psychiatrist, Mental Health Worker name & number

Legal Issues

Do you have pending legal issues?

If Yes, please explain

When and where is/are your court dates and in what city?

Felony (Y/N) What are the charges if Yes?

Misdemeanor (Y/N) What are the charges if Yes?

Are you on parole or probation?

What type of parole or probation? Formal or Informal?

Name of parole/probation officer and phone number

CPS Issues

Do you have an open CPS case?

Name of caseworker and phone number

List names and ages of the children involved in this case? Include Name, Age, Birthdates, Gender, School Attending

Brief History of Needs and Situation

How long have you been homeless in terms of days, weeks or months?

Have you been homeless before?

When & how long?

Where have you been homeless?

How did you become homeless?

Vehicle Information

Make, Model & Color

License Plate & State

PROJECT T.O.U.C.H. is not responsible for personal property.

Taking the following precautions can protect personal belongings. I understand that I am responsible for my personal belongings.

I consent

Engrave personal valuables with an ID number
Keep valuables in a safe place. Make a list of valuables for future reference.
Make sure all windows are secure
Do Not leave purses, computers, or other valuable items unattended
Report any suspicious activity
Make sure any prescriptions are secured and away from children and other clients either in a locked box or your vehicle.

Please list all prescription medications you are taking:

RELEASE OF LIABILITY

Project T.O.U.C.H. (PT) and the volunteer team do not make any promises to meet all your needs. However, PT and the volunteer team, to the best of their ability, will try to bring private organizations, individuals, churches & resources together to make a difference in acquiring assistance for your benefit and those of your family.

Signing this form releases Project T.O.U.C.H. (PT) and the volunteer team from all liabilities, including relinquishing any right to pursue any civil actions against PT, any of its staff, volunteers or any other affiliate of PT that may assist clients in any way.

Signature

Clear

Name

Date

BACKGROUND CONSENT STATEMENT

I understand Project T.O.U.C.H. (PT) will request a background check and sex offender registry check.

My signature below consents to the release of criminal and sex offender registry reports to PT. This background consent statement in original, fax, photocopied or any electronic form will be valid for any such reports that PT may request.

Signature

Clear

Name

Date

AUTHORIZATION for DRUG and ALCOHOL TESTS

I, the undersigned, know and understand that God’s Fan Club DBA PROJECT T.O.U.C.H. (PT) operates a drug and alcohol-free environment and that there is a policy that God’s Fan Club, dba PT will conduct random drug and alcohol testing. I fully understand that at any time during my stay, I may be required to submit to a drug and/or alcohol test. I also understand that failure to cooperate may result in my immediate dismissal.

Signature

Clear

Print Name

Date

Schooling Information

Names of school age children, Age, Grade and Gender

Are all children enrolled in school?

If no, why not?

What school(s) do they attend and what CITY?

Are there any special needs your children have for school? (ex. School supplies, internet, tutoring, etc.)

What can we do to help you meet these needs?

OPTIONAL SIGNING

Model Release

In consideration of the value received, receipt whereof is acknowledged. I hereby give God’s Fan Club DBA Project T.O.U.C.H. and its vendors the absolute right and permission to copyright and/or publish, or use photographic portraits or pictures of me, or in which I may be included in whole or in part, or composite or distorted in character or form, in conjunction with my own or fictitious name, or reproduction thereof in color or otherwise, made through any media at their studios or elsewhere, for art, advertising, trade or any other lawful purpose whatsoever at any time.

I hereby release, discharge, and agree to save God’s Fan Club DBA Project T.O.U.C.H. from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur to be produced in the taking of said picture, or in any processing tending toward the completion of the finished product.

Model Name

Model Signature:

Clear

Date

Parent or Guardian:

Witness

Notes

Do Not Wish to Participate (Yes or No)

Date

Please be aware that photos are taken inadvertently at events by groups who interact with the Project Touch program unknowingly by various participants.

EMERGENCY GUESTS STAY RULES & PROCEDURES

for PROJECT T.O.U.C.H. (PT) Program

Possession of illegal drugs, paraphernalia, alcohol, or weapons (knives, guns, or any other object that can cause bodily harm to others) while in the PT housing program is subject to immediate dismissal. Marijuana is not permitted. ZERO tolerance. CBD Products are allowed (but absolutely no THC).

I consent

No cussing or vulgar language.

I consent

Altercations with other clients, staff and/or leads in the program may cause you to be deemed not a fit for a shared living environment subject to immediate dismissal. _

I consent

Any damage caused to the unit, equipment or furnishings by you or anyone entering the program with you (i.e., spouse, children, etc.) could result in legal action.

I consent

I understand that I can be asked to leave the program immediately without notice if I am found in violation of any of the above listed situations. If asked to leave, I will do so peacefully immediately. If your behavior is deemed a threat to others or yourself, law enforcement may become involved.

I consent

Although PT has a disciplinary system based on write-ups and write-ups during your stay in our program, you may be subject to immediate dismissal. You may be asked to leave the program with less than three (3) write-ups if the action is deemed severe by staff/admin.

I consent

You must comply with the restriction of two suitcases or similar container size regarding the allowed amount of personal belongings in a shared space. Two suitcases or two plastic container bins. When exiting the program, any items left behind will be discarded after a total of 18 days.

I consent

Employment and/or job search is mandatory. Log sheets need to be filled out completely. Copies of work schedules and proof of income are required. Clients with disabilities will be evaluated on a case-by-case basis.

I consent

Neglecting to return a call to your case manager, accounting, or administration within a 12-hour period can result in disciplinary action.

I consent

AC controls cannot be set below 77 degrees and are not to be touched or adjusted at any time. House leads or staff can be notified if changes are needed. Heat cannot be set above 70 degrees.

I consent

You and your personal property is subject to be searched anytime

I consent

Curfew is 6:30 p.m. for the Emergency/Shelter guests to be on property in unit for the night. Please be inside your unit by 10:00 PM. If you have an emergency and need to stay out past curfew, you must notify your Case Manager for approval. All devices and lights are to be out at 11:00 p.m. Exceptions including work schedule must be approved by PT. in advance.

I consent

No cooking, showers, and no laundry after 9:00 p.m.

I consent

No outside visitors are allowed on the property (unless an approved caregiver or social worker). If someone is picking you up for an offsite visit, please have them phone you and remain in or at their vehicle.

I consent

Clients are not allowed to enter other client’s units

I consent

Monday through Friday, you are to be up and dressed and beds made by 8:00 a.m. You are working on your plan towards independence every week!

I consent

All movies must have a G or PG rating.

I consent

Do not touch anyone else’s belongings without permission. Do not eat food that is not yours unless it is “house food.”

I consent

Absolutely NO FOOD or BEVERAGE outside of dining area. Clear water only in the rooms.

I consent

Keep personal items in your assigned bedroom and assigned area unless in use. PT is not responsible for any personal items.

I consent

Absolutely no pets

I consent

Be mindful of your roommates while they are sleeping & not make noise.

I consent

NO sleeping on the couches unless you have prior approval from PT

I consent

Smoking is not allowed in the unit and must be 10 feet from the housing unit. Be mindful of those who do not smoke and what direction the smoke is flowing towards or smoke in designated smoking areas. You must throw away all cigarette butts!! They are not to be thrown on the ground!

I consent

Do not enter another bedroom that you are not assigned to

I consent

All beds must always have a mattress covers and bedspreads at all times.

I consent

Weekly or daily inspections will be done to ensure property condition, sanitation, and compliance with PT rules. This inspection will include bedrooms.

I consent

Any sign of BED BUGS by law, must be reported immediately or you could be held liable for related costs. Must give written notice of Bed Bugs sighting within (2) two days of actual knowledge. Civil Code 1954.605.

I consent

It is a crime to tamper with smoke detectors and/or fire extinguishers or to remove them and will result in immediate dismissal from the program and possibly prosecuted. Further, the California Penal Code Section 148.4 States the following: It is a misdemeanor crime to tamper with or break fire alarms or fire protection equipment.

I consent

Community service is a part of the PT program, and all emergency guests are required to perform community service. All clients are aware that they are obligated to serve community service hours to PT monthly based upon hours of employment. Tasks will be assigned according to the guest’s abilities.

I consent

Changing any PT locks is absolutely forbidden.

I consent

You are responsible for the actions of your children; please be sure they are respectful of roommates and their property as well as PT property.

I consent

I understand that I can be asked to leave the program immediately without notice if I am found in violation of any of the above situations. If asked to leave, I will do so peacefully and in a timely manner. If failure to comply will result in law enforcement involvement.

I consent

Your emergency stay time will go quickly (potentially up to 21 days but remember you are on a day-to-day probation status). It is your responsibility to discuss with your case manager your financial situation or staff to potentially go into transitional housing if approved. Any source of income during your emergency stays with failure to disclose this information and prioritize your housing, may consequently make you become ineligible for the Transitional Housing Program. We are here to help you, but you must participate in the process.

I consent

Name

Date

Please provide your signature

Clear

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