Transformation Life Center Emergency Shelter ApplicationPlease enable JavaScript in your browser to complete this form.Name *FirstMiddleLastMaiden Name *Date of Birth *Social Security Number *Phone Number *Last Address - (Street, City, State, Zip) *What County Are You From? *Race *Are You Hispanic/Latino? *YesNoGender *Marital Status *SingleMarriedSeparatedDivorcedWidowedOtherSpecial Needs You Have - Check All That Apply *Mental IllnessAlcohol AbuseDrug AbuseHIV/AIDS or Related DiseasePhysical DisabilityDomestic ViolenceOtherAre 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? *YesNoList Medications and Reason: *Please Explain Any Physical Conditions We Should Know About: *When Did You Last Have Permanent Housing? *What Circumstances Have Brought You to the Transformation Life Center? *Where Did You Stay Last Night? *Are You a Veteran (US Military)? *YesNoHow Long Have You Been Homeless? *Less Than 30 Days1-3 Months3-4 Months4-6 Months6 Months - 1 Year1-2 Years2-5 Years6-10 Years10 Years +How Many Times Have You Been Homeless?123-56+Have You Ever Been Convicted of a Sex Crime? *YesNoHave You Ever Been Convicted of a Violent Offense? *YesNoDo You Have Any Pending Criminal Charges? *YesNoList Any Service Agencies You Are Working With: *Do You Have a Source of Income? *YesNoIf Yes, From Where and How Much?Household Size (# of Family Members)Household Member One (SELF) (Full Name & Age) *Household Member Two (Spouse/Partner/Child/Other) (Full Name & Age) Household Member Three (Spouse/Partner/Child/Other) (Full Name & Age) Household Member Four (Spouse/Partner/Child/Other) (Full Name & Age) Household Member Five (Spouse/Partner/Child/Other) (Full Name & Age) Household Member Six (Spouse/Partner/Child/Other) (Full Name & Age) Submit