Adult Initial Application for Services

Name
Age
Date
Working Phone Number
Present or last known address:
Are you applying for:
Are you currently pregnant?
If you answered yes, how far along are you? Due Date?
Are you receiving pre-natal care?
If you answered yes, where?
Do you have Medicaid?
Do you have other insurance?
What is your current living situation?
If you answered Friends/Family or Other, please explain:
Do you have children that you will BRING WITH YOU 5 years or younger?
If Yes, please state their name, age and birthdate:
Do you have any behavioral/medical concerns about your children that live with you?
Are you on probation? If so, please list contact information
Are you working with any other agencies? If so, please list contact information ?
i.e.: homeless recovery, HKI, DCF
Are you involved with Eckerd/DCF? If so, please list your worker's name and phone number
Do you have another contact name and phone number?
How did you hear about us or who referred you?
Signature
Date