• CHESTER COUNTY DEPARTMENT OF MH/IDD

    Mental Health Supportive Housing Options Application

  • Date of application*
     / /
  • Gender:*
  • Format: (000) 000-0000.
  • Date of Birth:*
     / /
  • Please check to indicate application was completed with:*

  • Telephone/email (you may be called during the next Mental Health Housing Options Team (MHOT) meeting if there are questions about the application)

  • Format: (000) 000-0000.
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  • Does applicant meet homelessness criteria (HUD definition)?*
  • Does applicant meet chronically homelessness criteria (HUD definition)?*
  • Does applicant prefer to live:*

  • Medical Information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Special medical concerns:
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  • Social Service Agency Involvement:

  • Has applicant ever received Mental Health Supportive Housing and/or Supportive Housing Services in Chester County or any other County?*
  • Has applicant been involved with any other Mental Health service provider?*
  • Any past or present legal involvement?*
  • Is applicant currently on Probation or Parole?*

  • Education:

  • Please check the educational achievement(s) applicant has attained:*
  • Does applicant have a rep payee?*

  • Monthly Income(net, after taxes):

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  • Monthly Expenses:

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  • PERSONAL SUPPORT INFORMATION:

  • Does applicant have children?*
  • If yes, are they actively involved with their children?*

  • CHESTER COUNTY DEPARTMENT OF MH/IDD

    MEDICAL / PHYSICAL EXAMINATION FORM

  • Format: (000) 000-0000.
  • Date of Birth:
     / /
  • Medical History - Check all that apply:
  • Tobacco:
  • Alcohol:
  • Drugs:
  • Does the person wear eye glasses/contacts?
  • Does the person wear dentures?
  • Does person require any other adaptive equipment?

  • MEDICAL/PHYSICAL EXAMINATION FORM continued:

    Describe all Scars and Tattoos

  • Image field 77

  • Physical Examination Results

  • General Physical Health:

  • Tuberculosis test required per CRR regulations:

  • Date of PPD:
     / /
  • Date of Results:
     / /
  • Results:
  • Are there any communicable disease(s)?
  • Are there recommendations as a result of this physical?
  • Date of signature:
     / /

  • PSYCHOSOCIAL ASSESSMENT

  • Date of Psychosocial Assessment:*
     / /

  • Instructions:

    Select the rating number that best reflects applicant's current level of functioning, and enter the appropriate number in each space provided. Base your answers on how persons of similar age, gender, culture, and general background manage these activities in everyday living.

  • RATINGS FOR SECTIONS 1 THROUGH 8:

    1 - Totally dependent 
    2 - Needs substantial help/assistance 
    3 - Needs training or supervision 
    4 - Needs verbal cues/assistance
    5 - Self-sufficient

     

  • 1.  Self-Care/Preservation Skills:

  • Does the person need an interpreter?*
  • Does the person know and comprehend their rights?*
  • Does the person request to live with people who are of the same gender?*

  • 2.  Health-Care Skills:

  • 3.  Housekeeping Skills:

  • 4.  Nutritional Needs:

  • 5.  Mobility:

  • Is adaptive equipment needed for mobility purposes?*

  • 6.  Money Management:

  • 7.  Vocational/Education Pursuits:

  • Interest in pursuing educational goals.*
  • Marketable skills for employment consideration.*

  • 8.  Academic Skills:

  • RATINGS FOR SECTIONS 9 THROUGH 11

  • RATINGS FOR SECTIONS 9 THROUGH 11:

    0 - Not applicable
    1 - Never 
    2 - Rarely 
    3 - Occasionally
    4 - Frequently 
    5 - Almost always 

  • 9.  Use of Leisure Time:

  • 10.  Interpersonal/Social Skills:

  • 11.  Symptom Management:

  • Does the person utilize recovery tools to manage symptoms of their illness and their day-to-day life?
  • Has the person developed a WRAP or completed an Advanced Directive?

  • CHESTER COUNTY DEPARTMENT OF MH/IDD DRUG & ALCOHOL SCREENING

  • Format: (000) 000-0000.
  • Date or Interview:
     / /

  • Directions: Conduct a face-to-face interview.  Click "Yes" or "No" for each question.

  • 1. Have you ever felt you used drugs and/or alcohol excessively?
  • 2. Have you ever awakened the morning after drinking and/or drug use and found you could not remember a part of the evening before?
  • 3. Has your wife/husband/significant other/children/parents ever worried or complained about your drinking and/or drug use?
  • 4. Has your drinking or drug use ever made you feel unhappy?
  • 5. Have you ever tried to limit your drinking and/or drug use to certain times of the day or to certain places?
  • 6. Have you been able to stop drinking and/or using drugs when you wanted to?
  • 7. Have you ever attended an AA, NA or similar meeting(s)?
  • 8. Has your drinking and/or drug use ever created a problem with you or your family?
  • 9. Have you gotten into fights when drinking and/or using drugs?
  • 10. Has your wife/husband/significant other/family member ever gone to anyone for help about your drinking and/or drug use?
  • 11. Have you ever spent time with people you don't really care for just because of alcohol or other drugs?
  • 12. Have you ever spent money on alcohol or drugs that was supposed to be spent on other things (e.g. children's clothing, rent, food, etc.)?
  • 13. Have you ever lost a job because of drinking and/or drug use?
  • 14. Have you had problems at work or school (lateness, missed time, errors, etc.) due to drinking and/or drug use?
  • 15. Have you ever consumed alcohol and/or used drugs at the beginning of your day?
  • 16. Have you ever had a health problem as a result of drinking or drug use?
  • 17. Have you ever had D.T.'s, severe shaking, heard voices, or seen things that weren't there, after heavy drinking and/or drug use?
  • 18. Have you ever gone to anyone for help about your drinking and/or drug use?
  • 19. Have you ever been hospitalized because of your drinking and/or drug use?
  • 20. Were you ever arrested for an alcohol or drug related incident?
  • 21. Have you ever used alcohol or drugs in order to feel more comfortable around people?
  • 22. Have you ever taken a greater dosage of medication than was prescribed by your physician because you felt like you just needed more to cope?
  • 23. If you are accepted into Supportive Housing and/or Supportive Housing Services, are you willing to have unannounced urine screens?
  • 24. If you are accepted into Supportive Housing and/or Supportive Housing Services, are you willing to attend AA/NA (Double Trouble) meetings as recommended by your doctor and/or treatment team?
  • 25. Are you currently receiving D & A treatment?
  • 26. Have you ever received D & A treatment in the past?
  • 27. If currently receiving D & A treatment, are you receiving drug screenings?
  • 28. Have the interviewer and D & A provider communicated regarding recommendations and treatment?

  • Consent to Request or Release Consumer RecordsInformation

     

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