Shelter Application – Seneca County Council on Homelessness

Transformation Life Center Emergency Shelter Application

Full Name (including any previous names you have used, such as maiden, married, or other legal names) *

Date of birth *

Phone number *

Last address - (Street, City, State, Zip) *

What county do you currently reside in within Ohio?" *

Other Ohio counties or locations lived in the last 10 years: *

Race *

Are you Hispanic/Latino? *

Gender *

Marital status

Special needs you have - check all that apply *

Are you currently in treatment for any physical or mental health disorders? *

If yes, please list the name of the treatment agency, doctor, therapist, and/or case manager:

Education - highest grade completed: *

Are you a United States citizen? *

List medications and reason: *

Please explain any physical conditions we should know about: *

When did you last have permanent housing? If you are about to be homeless, what is your expected last date of housing? *

What circumstances have brought you to the transformation life center? *

Where did you stay last night? *

Are you a Veteran (US Military)? *

How long have you been homeless? *

How many times have you been homeless?

Have you ever been convicted of a sex crime? *

Have you ever been convicted of a violent offense? *

Do you have any pending criminal charges? *

List any service agencies you are working with: *

Do you have a source of income? *

If yes, from where and how much?

Household size (# of Family Members)

Please list each household member (Name, Age, Relationship to You). Example: (Jane Doe, 35, SELF), (John Doe, 4, Son) (etc)

Transformation Life Center