1

PROGRAM APPLICATION

Please answer all questions completely. All information is confidential.

I. INDENTIFYING INFORMTION

Date of Application

Maiden Name

Name (First, MI, Last)

Any other last names you have gone by

Current Address

City State County Zip

E-mail address

Phone Number

Cell Number

DOB Age

FL Driver’s License #

Work Number

Ethnicity SS Number

Are you a citizen of the United States? (CHECK ONE) YES NO

If no, are you authorized to work in the U.S.? YES NO

Person referring you to The New Beginnings

Relationship to referring person Phone

2

Briefly describe your religious beliefs

If referred by a church, please list the name of referring church

List previous addresses beginning with the most recent

Address Dates Reason for Moving

If The New Beginnings were unable to reach you at above phone, is there an alternate

number in which you can be reached?

Please list all social media account Names:

Facebook: _____________________________________

Twitter: ________________________________________

Instagram: _____________________________________

Snapchat: ______________________________________

II. MARITAL STATUS

(CHEK ONE) Married Divorced Never Married

(Ex)Husband’s Name: Age:

Describe your current relationship with your (ex)husband (include character, job,

education, car etc.):

3

List all previous marriages

Name Date of Marriage Date of Divorce

(Ex) Boyfriend’s name Age

Describe your current relationship with your boyfriend (include character, job, education,

car etc.)

III. CHILDREN

CHECK ONE WHERE YOU SEE “YES” AND “NO”.

Child’s Name Sex DOB Age Grade Father’s name

Are you currently pregnant? (CHECK ONE) YES NO Due Date:

4

Do you have legal custody of each of your children? YES NO If not, explain:

Do you or your children have any existing illnesses?

Please list all medications that you or your children currently take.

Have you or any of your children ever:

• Been prescribed an anti-depressant, anti-anxiety or any other psychotropic

medication? YES NO If yes, name of medicine and dosage:

• Attempted suicide or had any kind of suicidal thoughts? YES NO If so, please

explain:

• Had previous serious illness? YES NO

• Been hospitalized in past 12 months? YES NO

Do you or your children have any history of fire setting, aggressive behavior or cruelty to

animals? YES NO If yes explain:

5

Have you ever had any involvement with Dept. of Child & Families (DCF)?YES NO

If yes, please list date(s) and circumstances leading to the referrals.

Describe your relationship with your children:

Describe your children’s relationship with their father:

6

Describe your children’s relationship with their grandparents:

IV. APPLICANT’S FAMILY INFORMATION

Your Father’s Name Contact Number(s)

Address

Your Mother’s Name Contact Number(s)

Address

List names of your siblings, address, phone numbers & age:

7

Describe your relationship with your parents:

Other Supportive Relatives

Relationship Name Describe Relationship

V. PERSONAL INFORMATION

CHECK ONE WHERE YOU SEE “YES” AND “NO”.

Have you ever used drugs? YES NO List type and how often:

Do you smoke? YES NO If yes, how much?

Do you drink? YES NO If yes, how often?

Are you currently on probation?YES NO If yes, explain:

Have you ever had a psychological evaluation? YES No Date completed:

Who conducted the psychological evaluation?

9

Have you and/or your children been in a psychiatric hospital? YES NO

If yes, list dates and reason for hospitalization.

Have you ever lived in a shelter? YES NO

If yes, when and where:

Have you ever been in counseling? YES NO Dates:

Have you ever been physically abused? YES NO By whom?

Briefly explain:

What are your special interests and abilities?

Explain your circumstances:

10

What do you want to accomplish by enrolling in The New Beginnings Program?

VI. EDUCATION

CHECK ONE WHERE YOU SEE “YES” AND “NO”.

Last grade in school completed: Do you have a High School diploma or GED?YES NO

Have you taken any college entrance exams?YES NO

Are you currently enrolled in College? YES NO If yes, where:

Describe any other job training you have completed:

What are your EDUCATIONAL goals?

11

Have you received any loans for education at any time? YES NO If yes, explain:

Are you defaulting on any loan or credit card debt? YES NO If yes, explain on last page

VII. WORK HISTORY List employment, beginning with most recent

Business name

Address

Supervisor

Hourly Wage

Position

Dates Employed

Monthly Pay

Reason for Leaving

Business name

Address

Supervisor Dates Employed

Hourly Wage Monthly Pay

Position Reason for Leaving

12

Business name

Address

Supervisor

Hourly Wage

Position

Dates Employed

Monthly Pay

Reason for Leaving

What are your employment goals?

VIII. REFERENCES

Employer Reference

Name Phone Number

Business name and address

Family Member Reference:

Name Phone Number

Address Relationship

13

Friend Reference:

Name Phone Number

Address

Professional (Teacher, pastor, doctor, Sunday school teacher etc.):

Name Phone Number

Address

IX. TRANSPORTATION

CHECK ONE WHERE YOU SEE “YES” AND “NO”.

Do you have a car? qYES qNO

Model

License plate # Value

Running Condition

Do you have car insurance? YES NO Do you have a valid driver’s license? YES NO

Personal vehicles are not needed within the first 18 months of the TNB program.

Do you have medical insurance? YES NO If yes, with whom:

Do you receive Medicaid Benefits? YES NO Do you receive WIC assistance? YES NO

Make Year

Do you receive social security benefits? YES NO If yes, what is the amount?

14

Do you receive food stamps? YES NO Do you receive TANF? YES NO

Do you receive child support payments? YES NO If yes, what is the amount?

X. CRIMINAL HISTORY

Have you ever been convicted of a felony?

Have you been accused of any crimes involving children?

Have you been convicted of a misdemeanor?

If yes, explain:

Do you have a current indictment against you?

Are there current charges pending against you?

The information contained in this application is correct to the best of my knowledge. I

understand that the completion of application does not guarantee placement with The New

Beginnings.

SIGNATURE DATE

15

MONTHLY INCOME AND EXPENSES

INCOME

WAGES/JOB

CHILD SUPPORT

SOCIAL SECURITY

SSI

TANF

FOOD STAMPS

OTHER

TOTAL INCOME

EXPENSES

MEDICAL EXPENSES

HOUSING

Rent

Taxes

Electric

Gas

Water

Telephone

Maintenance

Other

INSURANCE

Auto payments

Life

Health

Other

DEBTS

Source Total Owed

Monthly Payment

Monthly Due Date

Amount Past Due

18

TOGETHER PROGRAM ~ Parent Needs Survey

Listed below are some needs commonly expressed by parents. Please put a check next to each item

if you need help in that area.

Childcare needs

Budgeting Skills

Finding

Medical/dental

resources for

myself/my child

Parenting skills

Information about

community

resources

Discipline

Techniques

Job skills

Resume writing

Increasing my self-

esteem

My relationship

with others

Counseling needs

for myself/my child

Information about

nutrition, feeding,

or buying food

Handling children’s

jealousy with their

brother or sister

Dealing with

problems with

relatives

Bible Studies

Help with education

or GED

Being more

assertive

Anger management

Time management

skills

Career counseling

Help with

addictions: (Circle

all that apply)

+Alcohol

+Drugs

+Smoking

+Pornography

Organizational skills

Housekeeping skills

Any other needs

(list)_________________

NAME DATE

19

Please explain why you should get a spot in the program…..