West Valley Health Equity Housing Application- The Magnolia House
Health Supported Housing for Pregnant and Parenting Women’
Date:
Email:
Email:
| Application Status | |
|---|---|
| Notes | |
| Date | |
| Name | |
| Preferred Name | |
| Date of Birth: | |
| Age | |
| Phone Number | |
| Text: | |
| Which gender do you identify with? | |
| Are you a member of the LGBTQ+ Community? | |
| Are you a member of a tribal nation? | |
| Marital Status | |
| AHCCCS # | |
| Plan | |
| Primary Care Doctor | |
| Date of Last Visit | |
| OBGYN | |
| Date of Last Visit | |
| Counselor | |
| Date of Last Visit | |
| Case Manager | |
| Date of Last Visit | |
| (Other Provider) | |
| Date of Last Visit | |
| Pregnant | |
| Due Date | |
| What is your current living situation? | |
| How did you find us? | |
| Name | |
| Relationship | |
| Address | |
| Name | |
| Relationship | |
| Address | |
| N/A | |
| Name | |
| Date of Birth | |
| Sex | |
| Name | |
| Date of Birth | |
| Sex | |
| Name | |
| Date of Birth | |
| Sex | |
| Name | |
|
| |
| Sex | |
| Currently lives with | |
| Relationship | |
| Currently lives with | |
| Chose | |
| Current DCS case | |
| Case Manager Name | |
| Phone | |
| Name | |
| Date of Birth | |
| Sex | |
| Currently lives with | |
| Relationship | |
| Chose | |
| Current DCS case | |
| Case Manager Name | |
| Phone | |
| Name | |
| Date of Birth | |
| Sex | |
| Currently lives with | |
| Relationship | |
| Chose | |
| Current DCS case | |
| Case Manager Name | |
| Phone | |
| Highest Grade Completed | |
| Diploma | |
| Employed | |
| Employed | |
| Child Support | |
| Social Security | |
| Cash Assistance | |
| SNAP | |
| WIC | |
| Other Forms of Income | |
| Monthly income amount | |
| Probation | |
| Offense | |
| Probation Officer Name | |
| Phone | |
| Parole | |
| Offense | |
| Please state any unresolved legal problems (warrants, fines, etc) | |
| Are you receiving Medical Assisted Treatment | |
| Location | |
| Prescription | |
| Date Started | |
| What substances have you abused in the past that you’re no longer using | |
| Are there any substances you are currently using? | |
| Do you need Detox Services | |
| Please describe your alcohol use | |
| Diagnosis | |
| Treatment | |
| Diagnosis | |
| Treatment | |
| Diagnosis | |
| Treatment | |
| Diagnosis | |
| Treatment | |
| Have you ever experienced any physical, emotional or sexual abuse | |
| If so, please explain |
