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Do You Need Help?
About Us
Contact Us
Get Involved
- Donate

Grandma’s House Application Form

– Step 1 of 8

Today's Date

Referred By

Applicant information

Applicant Name

First

Last

Preferred Name

Pronouns

Date of Birth

Phone

Last Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you experiencing homelessness right now?

Yes
No

Are you at risk of becoming homeless?

Yes
No

Where are you currently staying?

How soon do you need to come to Grandma's House

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Guardian Information

If under 18, who is your legal guardian?

Guardian's Name

First

Last

Guardian's Phone

Guardian's Address

Address Line 1

Address Line 2

City

State

Zip Code

Second Guardian's Name (if applicable)

First

Last

Second Guardian's Phone

Second Guardian's Address

Address Line 1

Address Line 2

City

State

Zip Code

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Pregnancy Information

Are you pregnant?

Yes
No
Unsure

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Has a pregnancy test been done?

Have you been seen by a doctor?

If yes, what is your dure date?

When?

Doctor's Name

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Child(ren's) Information

Do you have children?

Yes
No

If no, skip to Family Information

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Child Name

Age

Birth Date

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Pediatrician

Immunizations Current?

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Child Name

Age (copy)

Birth Date (copy)

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Pediatrician

Immunizations Current? (copy)

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Child Name

Age (copy)

Birth Date (copy)

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Pediatrician

Immunizations Current? (copy)

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Child Name

Age (copy)

Birth Date (copy)

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Pediatrician (copy)

Immunizations Current? (copy)

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Emergency Contact Information

Emergency Contact Name

First

Last

Emergency Contact Phone

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Educational Information

Are you currently in school

Yes
No

If yes, where?

Do you have your High School Diploma/ GED?

Yes
No

Are you interested in going back to school?

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Medical Health History

Are you prescribed any medication?

Yes
No

If yes, what medications?

Do you have allergies?

Yes
No

If yes, what allergies?

Do you have any of the following? Check all that apply.

Liver Disease
Kidney/ bladder problems
Sleep difficulty
Menstural Problems
Diabetes
Asthma
Epilepsy/ Seizures
Dizziness
High Blood Pressure
Heart Problems
Eating Disorder
Other Medical Issues

If you checked other medical issues – explain

Mental Health

Do you have a history of any of the following?

Depression
Anxiety
Suicide Attempts
School Problems
Family Conflicts
Self Harm
Running Away
Eating Disorder
Drug/ Alcohol Problems

Are you interested in any of the following?

Drug and Alcohol Treatment
Parenting Classes
Counseling
Help Getting Personal Documents
Life Skills Training
Employment Assistance
Nutrition Education
Child Birth Education Classes
Housing Navigation

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Legal Information

Have you had any arrests?

Yes
No

Are you on probation or parole?

Yes
No

If yes, name of PO

If yes, what are your charges?

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Your Goals

Goal #1

Goal #2

Goal #3

Goal #4

Do you have anything else you would like us to know?

Signature

Clear Signature

Date

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