Program Application

*Disclaimer-It is asked of each individual to complete this application as honestly as possible. The asnwers provided do not effect whether the applicant will be able to move into the Mountain Home Montana Program. Move in will be determined during an intake interview which will be scheduled after this application is completed and turned into Mountain Home Montana. The information requested is to allow us to provide the best possible services for our residents and meet each residents needs through a generalized individual plan.

  • Date
    MM
    /
    DD
    /
    YYYY
     

  • Section 1: Demographic Information

  • Applicant Name
    First
    Last
     
  • Date of Birth
    MM
    /
    DD
    /
    YYYY
     
  • Age
  • Race
  • Social Security Number
  • Child Name
    First
    Last
     

  • Thank you for completing the application! Our case manager will be in contact with you after they have received and reviewed your application.
  • Are you currently pregnant?
    Yes
    No
  • If yes, when is your due date?
    MM
    /
    DD
    /
    YYYY
     
  • Are you expecting twins?
    Yes
    No
  • Sex
  • Date of Birth
    MM
    /
    DD
    /
    YYYY
     
  • Age
  • Social Security Number
  • Race
  • Are they currently living with you?
    Yes
    No
  • Child Name
    First
    Last
     
  • Sex
  • Date of Birth
    MM
    /
    DD
    /
    YYYY
     
  • Age
  • Social Security Number
  • Are they currently living with you?
    Yes
    No
  • Race
  • Do you have any involvement with Child and Family Services?
    Yes
    No
  • If yes, with what children?
  • Who is your caseworker?
    First
    Last
     

  • Section 2: Income information

  • Do you receive:
    Supplemental Security Income (SSI)
  • SSI Amount
  • Social Security Disability Income (SSDI)
  • SSDI Amount
  • TANF
  • TANF Amount
  • Food Stamps
  • Food Stamps Amount
  • Unemployment
  • Unemployment Amount
  • Medicaid
  • Medicaid Amount
  • Child Support
  • Child Support Amount
  • Employment
  • Employment Amount
  • I do not have any Financial Resources
  • Total Monthly Income

  • section 3: special needs information

  • Please indicate any special needs:
    Mental Illness
    Alcohol Abuse
    Drug Abuse
    HIV/AIDS & related diseases
    Development Disability
    Physical Disability
    Domestic Violence
    Other
  • Please describe your special needs (name of illness or disability, special requirements, treatment):

  • section 4: Homeless Status

  • Did you just move to Missoula?
    Yes
    No
  • If yes, where did you move from?
  • How long have you lived in the community?
  • Where are you currently living/sleeping?
  • How long have you been there?
  • Are you currently homeless?
    Yes
    No

  • By HUD's definition, a homeless individual or family must meet the following criteria; please check which one is applicable to your current situation:
  • Currently living in a place not meant for human habitiation (street, car, parks, sidewalks, abandoned building etc.)
    In transitional housing for homeless persons
    In emergency shelter for homeless persons
    Being evicted from private dwelling
    Coming from a short term stay in an institution, previously resided on the street or in an emergency shelter
    Being discharged froma longer stay in an institution (treatment, prerelease etc.)
    Fleeing domestic violence
  • If you were living in a transitional or emergency housing program, please indicate where:
    Provide the name of the program in which you were residing
  • If you are coming from an institution, please indicate which institution and your release date:

  • Section 5: Contact Information

    Please give us the best way to contact you:
  • Current Address:
    Street Address
    Address Line 2
    City
    State / Province / Region
    Zip / Postal Code
    Country
     
  • Phone Number
    (###)
    -
    ###
    -
    ####
     
  • Can you receive texts:
    Yes
    No

  • Thank you!

    Thank you for completing the program application. Our Case Manager will review your application and contact you.