Am I Eligible? * Old Pueblo Community Services

Full name of applicant*

First Middle Last

ADC # if applicable

Date of Birth*

Ethnicity

Gender*

Male
Female

If you are female, are you pregnant?

Yes
No

Current living situation*

How can we contact you?*

Are you currently able to work?*

Yes
No

Are you receiving county, state or federal benefits? Check all that apply:

Food stamps
AHCCCS
Medicare
SSI
SSD
Veteran's benefits

Do you have children?

Yes
No

If yes, ages of children?

Emergency contact

First Last

Emergency contact relationship

Emergency contact phone

Emergency contact address

Street Address Address Line 2 City State ZIP Code

What was the date the last time you used drugs or alcohol?

(Current or past drug or alcohol use will not disqualify you from housing. )

What did you use?

List all current and chronic physical medical issues:

List all medications prescribed:

If you have ever been diagnosed with a mental health condition, list the condition:

Have you ever attempted suicide?

Yes
No

If yes, list date and circumstances:

Are you under the care of a health home? If so, choose one:

Who can we contact to share information included in this application?

Name

First Last

Facility

Phone

Email

Please feel free to share any more about yourself of your current situation:

By submitting this application, I provide OPCS authorization to share information included in this application and attest all information is true to the best of my ability.*

I agree

Name

This field is for validation purposes and should be left unchanged.

OPCS provides an assortment of housing options based on each individual’s need. If you are currently homeless and in need of a VI-SPDAT for a housing referral or other resources, please answer the following questions and an OPCS representative will contact you.

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