Date:
Dear Bridges Applicant:
Thank you for inquiring about Bridges to Housing Stability, Inc. Bridges is a non-profit transitional
housing program. It is a challenging program for homeless families that have the goal of becoming
self-sufficient.
Enclosed is the Application you requested along with an Agency Referral Form. If you are
working with an agency please give them the referral form to complete and return to us.
Please complete all parts of the Application and return it to Bridges. It is important that you be
honest and thorough. Dishonesty on any Application information will terminate your application
process.
Upon receiving and reviewing your completed Application, Bridges will contact you. Please note
Bridges does not usually have immediate openings and it can take months for a new family to be
accepted into the program.
Please note: Bridges will respond to the address the applicant provides on the Application.
The applicant must inform Bridges whenever that address changes.
All forms should be returned to:
Bridges to Housing Stability
9520 Berger Road, Suite 311
Columbia, MD 21046
Sincerely,
Pam DeCicco
Program Director
1
PRE-ADMISSION BACKGROUND QUESTIONNAIRE
Applicant Name: _____________________________________________ Date: _____________
1. Are you homeless? Yes ________ No _________
Where are you living now?
Non-Housing (street, park, car, etc.)
Domestic violence situation
Emergency/Motel Shelter
Rental, received eviction notice
Transitional housing for the homeless
With relatives/friends, required to leave
Other (please specify) _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
2. Do you have a Howard County Address or work in Howard County? Yes _______ No ______
3. Are you employed more than 30 hours per week or attending school and working part-time?
Yes ______ No ______
4. Have you been free of drugs or alcohol abuse for one year or more? Yes _______ No _______
(CCH does random drug screening)
5. Do you have a history of violent behavior? Yes ______ No ______
If you answered, “Yes” to questions 1-4 and “No” to question 5, you are eligible to apply
for the CCH transitional housing program. A drug screen, criminal background check, motor
vehicle records check, reference checks, credit check and employment verification will be
conducted for all applicants.
Referring Agency: ______________________________________________________________
Contact Name: _________________________________________________________________
Phone: _________________________________ Email: ________________________________
2
APPLICATION
Head of Household Background Information
Name:
SSN: _____ - _____ - _______ Date of Birth: ____ / ____ / _______ Gender: _____________
Phone:
Email:
Other Contact Information:
Current Howard County Address:
Mailing Address (if different):
Have you lived outside the state of Maryland in the last 7 years? If so, where did you live?
Marital Status (circle one): married/together married/separated
single
divorced
widowed
Are you currently working? Yes ____ No ____
Pay Rate:
Hours per week:
Length of time on job:
If the applicant is not working, please explain.
What is the cause of your homelessness (if more room is needed use a separate sheet of paper)?
3
Are you a veteran? Yes _____ No ______
What is your immigration status?
Where is your citizenship?
Do you have a driver’s license? Yes _____ No ______
Do you have a car? Yes _____ No ______
Do you have car insurance? Yes _____ No ______
Have you ever been convicted of a felony? Yes _____ No ______
Do you have any legal issues (custody, immigration, marital, financial)?
If yes, explain:
Do you have a history of substance abuse? Yes _____ No ______
If yes, what substance, how were you treated, and when did you last use?
Do you have health problems? Yes _____ No ______
If yes, explain:
Do you have health insurance? Yes _____ No ______
Do you have any special needs (mental illness, alcohol abuse, drug abuse, HIV/AIDS related
diseases, developmental disability, domestic violence, physical disability, or other)?
Yes ____ No ____ If yes, explain:
4
EDUCATION
Highest grade completed:
What date did you receive your high school diploma or GED?
How many years of college have you had?
What was/is the name of the college?
What was/is your major?
Are you currently enrolled? Yes
No
If yes, what is your expected graduation date?
Did you receive a degree? Yes
No
If yes, what is your degree in?
Have you had any other education, vocational training or have other qualifications/certifications?
(List all)
What language do you primarily speak?
How good are your English skills? (Write “F” for fluent. “S” for some or “N” for none.)
Speaking:
Writing:
Reading:
5
EMPLOYMENT (List your last 3 jobs)
Recent/Current Employer:
Dates of Employment:
Hours worked per week:
Rate of Pay:
Type of job, skills, duties:
Reason for leaving:
Supervisor’s name, title and phone:
Previous Employer:
Dates of Employment:
Hours worked per week:
Rate of Pay:
Type of job, skills, duties:
Reason for leaving:
Supervisor’s name, title and phone:
Previous Employer:
Dates of Employment:
Hours worked per week:
Rate of Pay:
Type of job, skills, duties:
Reason for leaving:
Supervisor’s name, title and phone:
6
Co-Applicant Background Information (if applicable)
Name:
SSN: _____ - _____ - _______ Date of Birth: ____ / ____ / _______ Gender: _____________
Phone:
Email:
Other Contact Information:
Current Howard County Address:
Mailing Address (if different):
Have you lived outside the state of Maryland in the last 7 years. If so, where did you live?
Marital Status (circle one): married/together married/separated
single
divorced
widowed
Are you currently working? Yes ____ No ____ Where?
Pay Rate:
Hours per week:
Length of time on job:
What is the cause of your homelessness (if more room is needed use a separate sheet of paper)?
Are you a veteran? Yes _____ No ______
7
What is your immigration status?
Where is your citizenship?
Do you have a driver’s license? Yes _____ No ______
Do you have a car? Yes _____ No ______
Do you have car insurance? Yes _____ No ______
Have you ever been convicted of a felony? Yes _____ No ______
Do you have any legal issues (custody, immigration, marital, financial)?
If yes, explain:
Do you have a history of substance abuse? Yes _____ No ______
If yes, what substance, how were you treated, and when did you last use?
Do you have health problems? Yes _____ No ______
If yes, explain:
Do you have health insurance? Yes _____ No ______
Do you have any special needs (mental illness, alcohol abuse, drug abuse, HIV/AIDS related
diseases, developmental disability, domestic violence, physical disability, or other)?
Yes ____ No ____ If yes, explain:
8
EDUCATION
Highest grade completed:
What date did you receive your high school diploma or GED?
How many years of college have you had?
What was/is the name of the college?
What was/is your major?
Are you currently enrolled? Yes
No
If yes, what is your expected graduation date?
Did you receive a degree? Yes
No
If yes, what is your degree in?
Have you had any other education, vocational training or have other qualifications/certifications?
(List all)
What language do you primarily speak?
How good are your English skills? (Write “F” for fluent. “S” for some or “N” for none.)
Speaking:
Writing:
Reading:
9
EMPLOYMENT (List your last 3 jobs)
Recent/Current Employer:
Dates of Employment:
Hours worked per week:
Rate of Pay:
Type of job, skills, duties:
Reason for leaving:
Supervisor’s name, title and phone:
Previous Employer:
Dates of Employment:
Hours worked per week:
Rate of Pay:
Type of job, skills, duties:
Reason for leaving:
Supervisor’s name, title and phone:
Previous Employer:
Dates of Employment:
Hours worked per week:
Rate of Pay:
Type of job, skills, duties:
Reason for leaving:
Supervisor’s name, title and phone:
10
FINANCES (for all adults in household)
Do you have an outstanding BGE bill? Yes ___ No ___ If yes, how much do you owe?
(applicants accepted into Bridges’ housing MUST be able to turn on BGE in their own name)
Total Cash-on-Hand Amount
$
Total Debt Amount
$
Total Monthly Expenses Amount $
Income Sources
Monthly Amount
Monthly Amount
(Head of Household)
(Co-Applicant)
Supplemental Security Income (SSI)
Social Security Disability (SSDI)
Social Security
General Public Assistance
Temporary Cash Assistance (TCA)
Child Support
Veteran’s Benefits
Self-Employment
Employment Income
Unemployment Income
Worker’s Compensation
Alimony
Other (specify)
No Financial resources
Have you ever filed for bankruptcy? Yes ____ No ____ If yes, when?
11
CHILDREN
Child #1 Information
Name (first and last):
Gender: M / F
Date of Birth: _____ / _____ / _______
SSN: _____ - _____ - _______
Other Parent’s Name:
Is the child living with you? Yes ____ No ____
Who has custody?
Receiving child support? Yes ____ No ____ If yes, how much monthly? $
Are the payments current? Yes ____ No ____ If not, have papers been filed? Yes ____ No ____
Does this child have any health issues? Yes ____ No ____ if yes, explain:
Does this child have any special needs? Yes ____ No ____ if yes, explain:
Has this child had any involvement with the criminal justice system? Yes ____ No ____
If yes, explain:
Child #2 Information
Name (first and last):
Gender: M / F
Date of Birth: _____ / _____ / _______
SSN: _____ - _____ - _______
Other Parent’s Name:
Is the child living with you? Yes ____ No ____
Who has custody?
Receiving child support? Yes ____ No ____ If yes, how much monthly? $
Are the payments current? Yes ____ No ____ If not, have papers been filed? Yes ____ No ____
Does this child have any health issues? Yes ____ No ____ if yes, explain:
Does this child have any special needs? Yes ____ No ____ if yes, explain:
Has this child had any involvement with the criminal justice system? Yes ____ No ____
If yes, explain:
12
Child #3 Information
Name (first and last):
Gender: M / F
Date of Birth: _____ / _____ / _______
SSN: _____ - _____ - _______
Other Parent’s Name:
Is the child living with you? Yes ____ No ____
Who has custody?
Receiving child support? Yes ____ No ____ If yes, how much monthly? $
Are the payments current? Yes ____ No ____ If not, have papers been filed? Yes ____ No ____
Does this child have any health issues? Yes ____ No ____ if yes, explain:
Does this child have any special needs? Yes ____ No ____ if yes, explain:
Has this child had any involvement with the criminal justice system? Yes ____ No ____
If yes, explain:
Child #4 Information
Name (first and last):
Gender: M / F
Date of Birth: _____ / _____ / _______
SSN: _____ - _____ - _______
Other Parent’s Name:
Is the child living with you? Yes ____ No ____
Who has custody?
Receiving child support? Yes ____ No ____ If yes, how much monthly? $
Are the payments current? Yes ____ No ____ If not, have papers been filed? Yes ____ No ____
Does this child have any health issues? Yes ____ No ____ if yes, explain:
Does this child have any special needs? Yes ____ No ____ if yes, explain:
Has this child had any involvement with the criminal justice system? Yes ____ No ____
If yes, explain:
(Use an additional page for more than four children)
13
I certify that all the information in this application is true and correct to the best of my
knowledge. I understand that incorrect or misleading information may result in rejection
of this application or dismissal from the program.
I authorize Congregations Concerned for the Homeless to conduct a criminal background
check, motor vehicle records check, reference check, credit check and employment
verification for all adult applicants.
I agree to submit to a drug test before acceptance in the program.
Head of Household Signature:
Date:
Co-Applicant Signature:
Date:
14
AGENCY REFERRAL FORM
Are you working with another agency or shelter? If so, please fill out the information on this
page. Then give the referral form to that agency so they can complete and return it to us.
Date:
I,
give
(applicant’s name)
(agency’s name)
permission to fill out the attached referral form and return it directly to Bridges to Housing
Stability. I also give said agency and Bridges to Housing Stability the right to disclose and
release all relevant information regarding me and my minor children.
Applicant’s Signature
Date
Please fill out the attached referral form and return it to Bridges by mail or fax:
Bridges to Housing Stability
9520 Berger Road, Suite 311
Columbia, MD 21046
Phone: 410-312-5760
Fax: 410-312-5765
Bridges to Housing Stability, Inc.
9520 Berger Rd., Suite 311, Columbia, MD 21046
Phone (410) 312-5760 Fax (410) 312-5765
www.Bridges2HS.org
REFERRAL FORM FOR AGENCIES
CANDIDATES FOR BRDIGES TO HOUSING STABILITY
TRANSITIONAL HOUSING PROGRAM
Date of Application
Client’s Name
Referring Agency Name
Address
Telephone
Contact Person
HISTORY OF YOUR AGENCY’S INVOLVEMENT WITH THE APPLICANT
(Please attach any case summaries, mental health evaluations, applicable progress notes)
Date applicant entered your program
How long have you been
working with the applicant?
Recommendations toward self –sufficiency:
What difficulties has this applicant encountered while participating in your program?
How were these difficulties resolved?
Has the applicant been cooperative in your program? Does the applicant follow through?
Is the applicant capable of living independently in a community of primarily homeowners?
16
Is the applicant a self-starter? Give an example.
If the applicant were accepted into CCH, what services would you provide?
What other community organizations is the applicant receiving resources from? (List all)
HOMELESS STATUS
Is the applicant “homeless” as defined by HUD (an individual who has a nighttime residence
that is a publicly or privately operated shelter designed for temporary living accommodations,
an institution that provides a temporary residence for persons intended to be institutionalized, or
a public or private place not designed for a regular sleeping accommodation)? If not, please
state the applicant’s situation.
Is the applicant’s income within Section 8 limits?
Has the applicant ever had a Section 8 voucher? Are there reasons that the applicant would not
receive a Section 8 voucher? Please explain.
Does the applicant have a criminal record or any pending charges? If so, please explain.
Bridges to Housing Stability, Inc.
9520 Berger Rd., Suite 311, Columbia, MD 21046
Phone (410) 312-5760 Fax (410) 312-5765
www.Bridges2HS.org
EMPLOYMENT STATUS/FINANCES
Is the applicant presently working? Yes _____ No ______ Where?
Pay Rate:
Hours per week:
Length of time on job:
If length of time is less than 3 months, please explain.
Does the applicant have the ability to be financially self-sufficient within two years? Please
explain.
EDUCATION
Does the applicant have a high school diploma, GED, college degree or certification in a specific
area of study?
Can the applicant speak English?
Can the applicant read and write?
Is the applicant currently receiving formal education? Where?
TRANSPORTATION
Does the applicant have a valid MD driver’s license?
Does the applicant have an automobile?
Does the applicant have automobile insurance?
Does the applicant have any unpaid fines from driving violations?
18
MENTAL HEALTH/PHYSICAL HEALTH
Would you recommend that the applicant seek or continue mental health counseling? If so,
please explain.
Is the applicant attending any weekly support group meetings?
Would you recommend and 12-step groups?
If the applicant has an addiction problem, how long has the applicant been in recovery?
Please list the applicant’s current health issues. Medication(s)?
Please list each dependent’s current health issues Medication(s)?
OTHER COMMENTS/RCOMMENDATIONS:
Counselor’s Signature
Date
Bridges to Housing Stability, Inc.
9520 Berger Rd., Suite 311, Columbia, MD 21046
Phone (410) 312-5760 Fax (410) 312-5765
www.Bridges2HS.org