The Promises Project, Inc.

Services Request/Application

To use this Application form, copy and paste it to your word processing software, then complete it and send to us via fax or mail.  Questions are asked only for the purpose of assisting clients and for gathering demographic information.  Answer questions to the best of your ability.  Failure to provide requested information will not disqualify an applicant from receiving services, but it may hamper our ability to provide  requested assistance.  If you have concerns about any questions, an Intake Specialist will assist you further at your intake interview. 

Applicant Information (Use back of page if needed for additional information)

Name:                                                                                                 Client #:

Date of birth:                 Age:

SSN(last 4 ONLY):

Phone:

Mailing address:

City:

State:

ZIP Code:

Single   Married  (Please Circle)

Ethnicity:

County of Current Residence:                                        County of Legal Residence:

Referred By:

In Recovery:  Yes   No

(Please circle)

How long?

In Treatment  Yes   No (Please circle)

Treatment Grad: Yes   No

(Please circle)

Year:

Services Requested

Income Tax Returns  - Family/Child Support -  Family Development—Life-Management

Finance Management—Personal Development– Communication Skills - (Please circle all that apply)

Income Taxes:  Federal   State  (Please circle)

Residence State:

Last Year you filed?

Desire Assistance: Yes   No (Please circle)

Finance Management

Accounts in Collection? Yes   No

Bank Account? Yes   No (Please circle)

Desire Info? Yes   No

Are you interested in attending a Finance Management Seminar?        Yes   No (Please circle)

Are you interested in attending a Communication Skills Seminar?    Yes   No (Please circle)

Family Development

Are you in touch with your Family?       Yes   No (Please circle)

Do you regard your relationships as Healthy? Yes   No (Please circle)

Would you like Family Development Assistance? Yes   No (Please circle)

Name of an alternate contact Person (Optional):

Address:

Phone:

City:

State:

ZIP Code:

Relationship:

Family and Child Support Information

Is Family Your Unified? Yes  No

Have you done Family or Marriage Counseling?  Yes  No (Please circle)

Family’s County of Residence:

City:

State:

Single      Married   (Please circle)

Children (How Many)

Gender (M or F)     ,     ,     ,     ,

Ages       ,       ,       ,       ,

Open Child Support Case (s):   Yes   No (Please circle)  Monthly payment:   1)                     2)

1) Case County:

State:

Current:  Yes  No

(Please circle)

2) Case County:

State:

Current:  Yes  No

(Please circle)

Additional Information

Currently employed: Yes   No (Please circle)     Annual income:

Employment Type:    Full-Time  Part-Time  (Please circle)  Temp? Yes  No

How long?

Phone:

Position:

Hourly     Salary     (Please circle)

Have you recently been Incarcerated Yes  No  (Please circle)

Parole:  Yes  No

(Please Circle)

Probation:  Yes  No

(Please Circle)

Release Date:

(Mo/Year)

Personal information will only be shared as permitted or required by law, or with the express permission of clients for the purpose of facilitating client-requested referrals to professional service providers or Promises Project Program Partners.  In such cases, only information that is reasonably necessary will be shared.

Signature of applicant                                                                              Date

Signature of co-applicant, (for joint application)                                                         Date