Central Iowa Community Services - CROSS Mental Health



County Rural Offices of Social Services (CROSS) For individuals living in: Clarke, Decatur, Lucas, Marion, Monroe, Ringgold & Wayne Application Date: Date Received by Office: ___________________________ First Name: ________________________ Last Name: _____________________MI: _________ Nickname: _________________________ Maiden Name: _______________________ Birth Date: _______________ Ethnic Background: FORMCHECKBOX White FORMCHECKBOX African American FORMCHECKBOX Native American FORMCHECKBOX Asian FORMCHECKBOX Hispanic FORMCHECKBOX Other __________Sex: FORMCHECKBOX Male FORMCHECKBOX Female US Citizen: FORMCHECKBOX Yes FORMCHECKBOX No If you are not a citizen, are you in the country legally? FORMCHECKBOX Yes FORMCHECKBOX NoSSN#____________________ Marital Status: FORMCHECKBOX Never married FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Separated FORMCHECKBOX WidowedLegal Status: FORMCHECKBOX Voluntary FORMCHECKBOX Involuntary-Civil FORMCHECKBOX Involuntary-Criminal FORMCHECKBOX Probation FORMCHECKBOX Parole FORMCHECKBOX Jail/PrisonAre you considered legally blind? FORMCHECKBOX Yes FORMCHECKBOX No If yes, when was this determined? __________________Primary Phone #: ____________________________________ May we leave a message? FORMCHECKBOX Yes FORMCHECKBOX NoCurrent Address: StreetCityState Zip CountyBegin Date ______________________________I live: FORMCHECKBOX Alone FORMCHECKBOX With Relatives FORMCHECKBOX With Unrelated persons FORMCHECKBOX Use as current Mailing Address: FORMCHECKBOX Yes FORMCHECKBOX No If not, _________________________________________________Previous Address_______________________________________________________________________________________StreetCityState ZipCountyBegin Date___________________ End Date___________________Current Service Providers:NameLocation____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current Residential Arrangement: (Check applicable arrangement) FORMCHECKBOX Private Residence FORMCHECKBOX Foster Care/Family Life Home FORMCHECKBOX Correctional Facility FORMCHECKBOX Homeless/Shelter/Street FORMCHECKBOX Other______________________________ Veteran Status: FORMCHECKBOX Yes FORMCHECKBOX No Branch & Type of Discharge: ____________________Dates of Service: ______________Current Employment: (Check applicable employment) FORMCHECKBOX Unemployed, available for work FORMCHECKBOX Unemployed, unavailable for work FORMCHECKBOX Employed, Full time FORMCHECKBOX Employed, Part time FORMCHECKBOX Retired FORMCHECKBOX Student FORMCHECKBOX Work Activity FORMCHECKBOX Sheltered Work Employment FORMCHECKBOX Supported Employment FORMCHECKBOX Vocational Rehabilitation FORMCHECKBOX Seasonally Employed FORMCHECKBOX Armed Forces FORMCHECKBOX Homemaker FORMCHECKBOX Volunteer FORMCHECKBOX Other __________ Current Employer: Position: Dates of employment: ______________________ Hourly Wage: ________________ Hours worked weekly: ______Employment History: (list starting with most recent to previous.) Employer City, State Job Title Duties To/From1.2.Education: What is the highest level of education you achieved? ______ # of years ______ DegreeEmergency Contact Person: Name: Relationship: Address:_________________________________________Phone: _____________________________Guardian/Conservator appointed by the Court? FORMCHECKBOX Yes FORMCHECKBOX No Protective Payee Appointed by Social Security? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Legal Guardian FORMCHECKBOX Conservator FORMCHECKBOX Protective Payee FORMCHECKBOX Legal Guardian FORMCHECKBOX Conservator FORMCHECKBOX Protective Payee (Please check those that apply & write in name, address etc.) (Please check those that apply & write in name, address etc.) Name: _______________________________________ Name: _______________________________________ Address: ______________________________________ Address: _____________________________________ Phone: _______________________________________ Phone: ______________________________________ List All People In Household: Name Age RelationshipSocial Security Number1.2.3.4.5.INCOME: Proof of income may be required with this application including but not limited to pay-stubs, tax-returns, etc.If you have reported no income above, how do you pay your bills? (Do not leave blank if no income is reported!) ______________________________________________________________________________________________________________________________________________________________________________________________________Gross Monthly Income (before taxes): Applicant Others in Household (Check Type & fill in amount) Amount: Amount: FORMCHECKBOX Social Security FORMCHECKBOX SSDI FORMCHECKBOX SSI FORMCHECKBOX Veteran’s Benefits FORMCHECKBOX Employment Wages FORMCHECKBOX FIP FORMCHECKBOX Child Support FORMCHECKBOX Rental Income FORMCHECKBOX Dividends, Interest, Etc. FORMCHECKBOX Pension FORMCHECKBOX Other Total Monthly Income:Household Resources: (Check and fill in amount and location): Type Amount Bank, Trustee, or Company FORMCHECKBOX Cash FORMCHECKBOX Checking Account FORMCHECKBOX Savings Account FORMCHECKBOX Certificates of Deposit FORMCHECKBOX Trust Funds FORMCHECKBOX Stocks and Bonds (cash value?) FORMCHECKBOX Burial Fund/Life Ins (cash value?) FORMCHECKBOX Retirement Funds (cash value?) FORMCHECKBOX Other __________________________________________________________________________________________ Total Resources: Motor Vehicles: FORMCHECKBOX Yes FORMCHECKBOX No Make & Year: ___________________ Estimated value: _________________________(include car, truck, motorcycle, boat, Make & Year: ___________________ Estimated value: _________________________recreational vehicle, etc.)Make & Year: ___________________ Estimated value: _________________________Do you, your spouse or dependent children own or have interest in the following: House including the one you live in? FORMCHECKBOX Yes FORMCHECKBOX No Any other real estate or land? FORMCHECKBOX Yes FORMCHECKBOX No Other?________ FORMCHECKBOX Yes FORMCHECKBOX NoIf yes to any of the above, please explain: ____________________________________________________________________________________________________________________________________________________________________Have you sold or given away any property in the last five (5) years? FORMCHECKBOX Yes FORMCHECKBOX No If yes, what did you sell or give away?_________________________________________________________________________________________________________Health Insurance Information: (Check all that apply) Primary Carrier (pays 1st) Secondary Carrier (pays 2nd) FORMCHECKBOX Applicant Pays FORMCHECKBOX Medicaid FORMCHECKBOX Iowa Health and Wellness FORMCHECKBOX Applicant Pays FORMCHECKBOX Medicaid FORMCHECKBOX Iowa Health and Wellness FORMCHECKBOX Medicare A, B, D FORMCHECKBOX Medically Needy FORMCHECKBOX MEPD FORMCHECKBOX Medicare A, B, D FORMCHECKBOX Medically Needy FORMCHECKBOX MEPD FORMCHECKBOX No Insurance FORMCHECKBOX Private Insurance FORMCHECKBOX HAWK-I FORMCHECKBOX No Insurance FORMCHECKBOX Private Insurance FORMCHECKBOX HAWK-I Company Name Company Name ______ Address Address ______ ________________________________ Policy Number: Policy Number__________________________ (or Medicaid/Title 19 or Medicare Claim Number) (or Medicaid/Title 19 or Medicare Claim Number) Start Date: _____________Any limits? FORMCHECKBOX Yes FORMCHECKBOX No Start Date: _____________ Any limits? FORMCHECKBOX Yes FORMCHECKBOX NoSpend down: ___________Deductible: ____________ Spend down: ___________Deductible: ____________Referral Source: FORMCHECKBOX Self FORMCHECKBOX Community Corrections FORMCHECKBOX Family/Friend FORMCHECKBOX Social Service Agency FORMCHECKBOX Targeted Case Management FORMCHECKBOX Other FORMCHECKBOX Other Case Management Have you applied for any of the public programs listed below? (Please check those you have applied for and the status of your referral) Has your application been Approved or Denied? If denied and you appealed, what is the date of appeal ____________ Have you applied for reconsideration. Have you had a hearing with an Administrative Law Judge and what was the date of the scheduled hearing: ______________ FORMCHECKBOX Social Security____________________ FORMCHECKBOX SSDI_____________________ FORMCHECKBOX Medicare_____________________ FORMCHECKBOX SSI _____________________________ FORMCHECKBOX Medicaid_________________ FORMCHECKBOX DHS Food Assistance:_____________ FORMCHECKBOX Veterans _________________________ FORMCHECKBOX Unemployment____________ FORMCHECKBOX FIP _________________________ FORMCHECKBOX Other____________________ FORMCHECKBOX Other____________________Disability Group/Primary Diagnosis: (If known) FORMCHECKBOX Mental Illness FORMCHECKBOX Chronic Mental Illness FORMCHECKBOX Intellectual Disability FORMCHECKBOX Developmental Disability FORMCHECKBOX Substance Abuse FORMCHECKBOX Brain Injury Specific Diagnosis determined by:____________________________________________________ Date:__________Axis I: _____________________________________________________Dx Code: _______________________Axis II:_____________________________________________________ Dx Code: _______________________Why are you here today? What services do you NEED? (this section must be completed as part of this application!)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I certify that the above information is true and complete to the best of my knowledge, and I authorize County staff to check for verification of the information provided including verification with Iowa county government and the state of Iowa Dept. of Human Services (DHS) and Iowa Department of Corrections or Community Corrections staff. I understand that the information gathered in this document is for the use of the county in establishing my ability to pay for services requested, and in assuring the appropriateness of services requested. I understand that information in this document will remain confidential. Applicant’s Signature (or Legal Guardian)Date___________________________________________________________________________________________________Signature of other completing form if not Applicant or Legal Guardian Date100 S Main, Osceloa, IA 50213Ph: 641-414-2968 Fax: 641-342-7076Email: clarkecountymentalhealth@201 NE Idaho Street, Leon, IA 50144Ph: 641-446-7178 Fax: 641-446-8208Email: tammy.harrah@125 S. Grand, Chariton, Iowa 50049Ph: 641-774-0423 Fax: 641-774-4383Email: egbertk@2003 N. Lincoln PO Box 627, Knoxville, IA 50138 Ph: 641-828-8149 Fax: 1-888-434-1890 Email: tiffany.hopkins@1801 S. B. Street, Albia, IA 52531Ph: 641-932-2427 Fax: 641-932-2578Email: kfisher@monroecoia.us109 West Madison, Mount Ayr, Iowa 50854Ph: 641-464-0691 Fax: 641-464-2476Email: bfletchall@101 N. Lafayette, Box 435, Corydon, IA 50060Ph: 641-872-1301 Fax: 641-872-2843Email: waynecpc@ ................
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