WIP - Enrollment Application Form w Updates About Us 1145 Washington St | Boston, MA 02118 | Tel: (617) 542-3740 | Fax: (617) 542-3860Any information we ask on the application is used to help us to best support you in obtaining employment and housing. It is important to complete all sections of this application. An incomplete application will not be considered. All information you provide on this application is considered confidential. Criminal history will not disqualify you from our services.Project Place does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.Today's Date(Required) Month Day Year Who is filling out this form?(Required)Individual seeking to enrollReferrer assisting clientIs a Project Place staff member assisting you with this application? yes no What is the Project Place staff member's name? Referrer Section StartName of Referring Agency Agency Address Referrer's First Name Referrer's Last Name Client's Current Address, City, State Zip (Please also include the name of the Shelter, Treatment Program of Halfway House if applicable):Purpose of Referral: Project Place Staff with whom you are working (if any): End of Referrer SectionDemographic InformationDate of Birth(Required) Month Day Year First Name(Required) Last Name(Required) Preferred Pronouns he/him she/her they/them Other Current Email(Required) Current PhoneSocial Security Number(Required) Gender(Required) Male Female Non-Binary Other Do you identify as Transgender?(Required) yes no prefer not to say Racial Identity. Choose all that apply:(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Ethnic Identity. Choose one:(Required) Hispanic/Latino Non-Hispanic/Latino Please note any preferred race, ethnicity, gender, religious or personal identities if not included:Is English your first language?(Required) yes no Please list your primary language: Do you speak any other languages?(Required) yes no Please list any other languages you speak: Are you receiving (check as many as apply): SSI/SSDI SNAP TANF Other Federal assistance Please list other: Do you identify as homeless?(Required) yes no Name of Shelter/Program, if you are in one Case Manager/Counselor Name Case Manager/Counselor Phone NumberCurrent Address:(Required) Zip Code(Required) EducationHighest Level of EducationNo High School Diploma or EquivalentHigh School GraduateGED or EquivalentAssociate's DegreeBachelor's DegreeMaster's DegreeHighest grade level completed? Do you know how to use a computer?(Required) yes no Do you know how to use a smartphone?(Required) yes no On a scale of 1-5, how confident are you in using technology?(Required)12345 No Confidence Very Little Confidence Somewhat Confident Pretty Confident Very Confident Military ServiceHave you ever served in the Military?(Required) yes no Which branch? Army Air Force Marines Navy Start date of service: Duration of service (months) Nature of Discharge: General Medical Bad Conduct Dishonorable Honorable Don't Know EmploymentAre you interested in finding employment?(Required) yes no Approximately how many hours a week can you work? Are you a US Citizen?(Required) yes no Are you eligible to be employed in the US?(Required) yes no Do you have a valid ID?(Required) yes no Medical InformationDo you have medical insurance?(Required) yes no Name of insurance provider: Do you have a Primary Care Doctor?(Required) yes no Primary Care Doctor's Name: Where do you currently receive medical care? Do you have any physical disabilities that would affect your ability to work?(Required) yes no Please list diagnosis, year diagnosed, and any medication, hospitalization or other treatments you have taken as a resultHave you ever been diagnosed with a learning or developmental disability?(Required) yes no Please list diagnosis, year diagnosed, and any medication, hospitalization or other treatments you have taken as a resultDo you have a mental health diagnosis(Required) yes no Please list diagnosis, year diagnosed, and any medication, hospitalization or other treatments you have taken as a resultAre you currently seeing a therapist or counselor?(Required) yes no Therapist, How Often? Are you currently seeing a a prescriber or psychiatrist?(Required) yes no Psychiatrist, How Often? Do you have a history of addiction?(Required) yes no Are you working with ATR (Access To Recovery)?(Required) yes no Name of ATR Coordinator: Are you able to provide 3rd party verification of your sobriety by confirming you reside in a substance treatment program or receive regular drug screens from a medical professional and/or probation/parole department? yes no Do you consent to have a drug screen?(Required) yes no What is the current length of your sobriety?(Required) HousingWhere did you stay last night? How long do you plan to stay there? What is your last complete permanent address? IncarcerationPLEASE NOTE: Criminal history will not disqualify you from our services. As a part of our programming, Project Place will run your CORI at no cost to you. Your case manager will assist you with supports and services related to your CORI.Do you have any prior criminal convinctions or incarcerations?(Required) yes no Have you been incarcerated within the past 6 months?(Required) yes no Dates of incarcerationDo you have any of the following charges on your record? Drug Offenses: Possession, Distribution, Trafficking Fraud, Forgery, Counterfeiting Probation or Parole Violations Property Offenses: Arson, Breaking and Entering, Home Invasion, Larceny, Robbery, Vehicle Theft, Willful and Malicious Destruction of Property Sex Offenses: Indecent Assault, Rape Violent Offenses: Assault & Battery, Manslaughter, Murder Do you have any open court cases?(Required) yes no Please list court date(s)Are you currently on supervision? yes no What kind of supervision? State Probation Federal Probation Parole Community Supervision Supervision end date: Name of Officer Officer Phone NumberOk to contact? yes no Personal InformationWhat are my short-term goals?(Required)What are my long-term goals? Where do I want to be in 5 years? 10 years?(Required)How do I want Project Place to help me?(Required)What are some challenges or road blocks that I may face?(Required)What are my strengths? What skills do I have? What do I contribute? How do I help myself, my family, and my community?(Required)Additional Contact InformationLast part and you're done! Finally, list up to 2 backup contacts for us to call should we be unable to reach you about your appointmentsPerson 1Name Relationship to you Phone/Email Person 2Name Relationship to you Phone/Email
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