The Center of Concern Transitional Housing Program Inquiry Form Mail to: The Center of Concern, 1530 N. Northwest Hwy., Suite 310, Park Ridge, IL 60068 Date: _________________ Date of Birth: ___________________ Name: ____________________________________________________________ Address: __________________________________________________________ Phone: Home ______________________ Work __________________________ Number of family members living with you: _____ Referred by: _______________________________________________________ Describe your current living situation (including where you have stayed in the past year): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Employer’s name, address: ____________________________________________ ______________________________________________________________________ Pay rate and hours worked per week: ____________________________________ If unemployed, explain: ______________________________________________________________ Other sources of income: Unemployment $______ Workman’s Comp $______ SSI $_______ SSDI $________ SSA $__________ Child Support $_________ Pension $________ TANF $_________ Other (Specify) $ ________ Any special health care needs for you or family members? ________________________________ ___________________________________________________________________________________ Do you smoke or drink? _______ How often? _____________________________ Likes, dislikes, hobbies, lifestyle _____________________________________________________ ___________________________________________________________________________________ |