Northeast Iowa Counties Cpc/community Services Howard County Cpc Application Form
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5NORTHEAST IOWA COUNTIES CPC/COMMUNITY SERVICES
HOWARD COUNTY CPC
Application Form
Application Date:
Date Received by CPC Office: ____________________________
Last Name:
First Name: __________________________ MI: __________
Phone #:_________________ Birth Date:_____________ SSN#______________________ State ID#___________________
Current Address:
Street
City
State
Zip
County
Sex:
Male
Female
Ethnic Background:
White
African American
Native American
Asian
Hispanic
Other _______
Guardian/Conservator appointed by the Court?
Yes
No
Protective Payee Appointed by Social Security?
Yes
No
Legal Guardian
Conservator
Protective Payee
Legal Guardian
Protective Payee
Conservator
(Please check those that apply & write in name,address etc.)
(Please check that apply & write in name, address etc.)
Name: _______________________________________
Name: _______________________________________
Address: ______________________________________
Address: _____________________________________
Phone: _______________________________________
Phone: ______________________________________
Veteran Status:
Yes
No Branch & Type of Discharge: ____________________Dates of Service: ______________
Marital Status:
Never married
Married
Divorced
Separated
Widowed
Legal Status:
Voluntary
Involuntary-Civil
Involuntary-Criminal
Probation
Parole
Jail/Prison
Are you here in the U.S. legally?
Yes
No Living Arrangement:
Alone
With relatives
With unrelated persons
Current Residential Arrangement:
(Check applicable arrangement)
Private Residence
State Resource Center
Supported Comm. Living
State MHI
Foster Care/Family Life Home
RCF/MR
RCF/PMI
RCF
ICF
ICF/PMI
Correctional Facility
Homeless/Shelter/Street
ICF/ MR
Other________________________________
Disability Group/Primary Diagnosis:
Mental Illness
Chronic Mental Illness
Mental Retardation
Developmental Disability
Substance Abuse
Brain Injury
Specific Diagnosis determined by:_________________________________________________________ Date:__________
Axis I: _____________________________________________________Dx Code: ____________________________
Axis II:_____________________________________________________ Dx Code: ____________________________
If agency referral, name of agency/contact person and contact information: _____________________________________
Referral Source:
Education:
Self
Community Corrections
Years of Education: _________________
Family/Friend
Social Service Agency
GED:
Yes
No
Targeted Case Management
Other
H.S. Diploma:
Yes
No
Other Case Management
College Degree: ____________________
Why are you here today? What services do you NEED? (this section must be completed as part of this application!)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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