About Us | Transforming Lives | First Fruit Ministries

First Name

Middle Name

Last Name

Date

Age

Date of Birth

Last four digits of your Social Security Number

Your Phone Number

Other Phone Number

Email Address

Who are you applying for?

just for yourself

or for you and family members

Have you read our Program Guidelines? If no, please do so.

Yes

No

About you

Please answer every question in full. Incomplete applications will not be considered.

Your Marital Status:

Your Gender:

Female

Male

Transgender

Your Primary Race (Check only one)

American Indian or Alaskan Native

African American or Black

Native Hawaiian or other Pacific Islander

White

Asian

Secondary Race (Check only one and Only if multi-racial)

American Indian or Alaskan Native

African American or Black

Native Hawaiian or other Pacific Islander

White

Asian

Ethnicity (Check only one)

Hispanic/Latino

Non-Hispanic/Non-Latino

Are you a veteran?

Yes

No

Have you ever served in the military?

Yes

No

Have you ever served in a war zone?

Yes

No

Do you receive Veteran’s benefits? if yes, write monthly amount

Please tell us the name, address, and phone number of your Next-of-kin:

Please tell us the name, address, and phone number of your emergency contact:

Your Driver’s License or State ID Number is

State Issued

Valid?

Yes

No

Your Current Living Situation

Approximate Date Homelessness Started

Where did you sleep last night? (Shelter or Street Address)

Where are you sleeping now? (check one)

How long have you been staying where you are now?

One day or less

Two days to one week

More than one week, but less than one month

One to three months

More than three months, but less than on year

One year or longer

Is homelessness due to a natural disaster?

Yes

No

Including now, how many times in the past 3 years have you been homeless - in a place not meant for human habitation, or an emergency shelter, or a safe haven?

In the past three years, how many months have you been homeless?

What was your last permanent (90 days or more) address? (Address, City, country, state, Zip code)

Have you lived at First Fruit Ministries before? if yes, What dates?

Please tell us briefly a little more about what has happened in the recent past that has led to you being homeless

Your Health History

Are you a domestic violence victim/survivor? If yes, when did the experience occur?

No

Within the past three months

Six months to one year ago

Three to six months ago

One year ago or more

Are you currently fleeing or attempting to flee a domestic violence situation?

Yes

No

Does the person know where you are?

Yes

No

Name/description of person involved

Does anyone have a restraining order against you? If so, who, and for what reason?

Have you ever worked [or done other activities] without getting the payment you were promised?

No (If no, skip the 5 questions below)

Yes (If yes, answer the 5 questions below)

If yes, what kind(s) of work or activities were you doing?

What payment did you expect and why?

What did you receive?

Did anyone where you worked [or did other activities] ever hurt you or threaten to hurt you?

No

Yes

Could you tell me what they did or said?

Special Needs or disabilities? (check all that apply):

Pregnant Due Date

If you have any physical disabilities please tell us about them and include the month/year they started:

Have you received a

disability determination

or applied for one

If yes, when have you received a disability determination or applied for one?

If you have any developmental disabilities please tell us about those

Have you been diagnosed with a mental health problem? if yes, what is your diagnosis?

Are you currently seeing a mental health professional? if yes, who is that and when was your last visit?

Has the use of alcohol ever resulted in a life problem (DUI, hurt relationships, lost jobs, etc.?)

Yes

No

Are you an alcoholic?

Yes

No

Has the use of illegal drugs or substances like Spice ever resulted in a life problem? if yes, please tell us which drugs and when you used them

What is the date you last had an alcoholic drink, use an illegal drug, or substance like Spice?

How old were you when you started drinking and/or taking drugs?

If alcohol or drugs have resulted in life problems, are you currently going to AA or NA meetings?

Yes

No

Do you have a sponsor?

Yes

No

Are you working the steps?

Yes

No

Please list all medications you are currently taking and what they are for

Are you currently or have you previously received in or out patient treatment for addiction or mental health needs?

Yes

No

What types of out-patient services, when, and through what agency:

What types of in-patient services, when, and through what agency:

If you have health insurance, what type and which company?

Do you receive Medicaid?

Yes

No

Do you receive Medicare?

Yes

No

Please list which agencies are currently providing supportive service (i.e., job search, mental health) to you and what kind of service they are providing.

Criminal History

Have you ever served time in jail/prison? if yes, please tell us the dates, where you served and what your conviction(s) were for:

Are you currently on probation? if yes, For what reason?

Name of and phone number for your probation officer:

Do have any current charges pending? If yes, what are they for?

What is your highest level of education?

Did you obtain a

GED?

or High School Diploma?

College level degree or certification?

What degree or certification?

If you are currently enrolled in school please tell us which school and which program

Have you ever received vocational or job skills training? If yes, what kind?

Right now, you are:

If Other, describe

If you are working, please tell us who your employer is:

If not employed, are you receiving unemployment/worker’s compensation benefits?

Yes

No

Are you currently working with any agencies that are providing employment assistance to you? If yes, which agencies

Name of your last employer:

Position held:

Last date of employment?

Reason for leaving?

What types of work have you done in the past?

Household Information:

Household Information

Children - please list your children, including those adopted out, in foster care, and deceased.

1st Child: Full Name

Age

Date of Birth

Gender

Race

Ethnicity

Last 4 digits Social Security #

Who does she/he live with?

Relationship

Father’s Name

Is he involved in the child’s life?

Do you have a legal agreement?

Is child enrolled in daycare or school?

What school and grade level?

Does an agency provide childcare? Who?

Do you receive financial assistance for childcare? By whom and how much?

Do you receive child support? Amount And from whom?

2nd Child: Full Name

Age

Date of Birth

Gender

Race

Ethnicity

Last 4 digits Social Security #

Who does she/he live with?

Relationship

Father’s Name

Is he involved in the child’s life?

Do you have a legal agreement?

Is child enrolled in daycare or school?

What school and grade level?

Does an agency provide childcare? Who?

Do you receive financial assistance for childcare? By whom and how much?

Do you receive child support? Amount And from whom?

3rd Child: Full Name

Age

Date of Birth

Gender

Race

Ethnicity

Last 4 digits Social Security #

Who does she/he live with?

Relationship

Father’s Name

Is he involved in the child’s life?

Do you have a legal agreement?

Is child enrolled in daycare or school?

What school and grade level?

Does an agency provide childcare? Who?

Do you receive financial assistance for childcare? By whom and how much?

Do you receive child support? Amount And from whom?

Have you ever been investigated by DSS? If yes, relating to which children?

Please explain, including the results of the investigation:

Please list the sources of your monthly income and the amount received from each:

Your Monthly Resources

Do you currently have a monthly income? If yes, please show the amount

Alimony or other spousal support

Child support

Earned income (Employment)

Pension or retirement Income from a former job

Private disability insurance

Retirement income from social security

SSDI (Social Security Disability Income)

SSI (Social Security Income)

TANF (Temporary assistance for Needy Families or FIP) grant

Unemployment Insurance

VA Service-Connected Disability Compensation

VA Non-Service Connected Disability Pension

Workers Compensation

No Financial Resources

If Other, please specify and write amount

Total Monthly Income Reported

Please list the sources of any monthly non-cash benefits and the amount received from each:

SNAP – Supplemental Nutrition Assistance Program (Food Stamps)

Special Supplemental Nutrition Program for WIC

TANF Child Care Services

TANF Transportation Services

Other TANF Funded Services

Section 8, Public Housing or rental assistance

Other Source and amount

What would you do if there were no obstacles you could not overcome? What is your dream for your future?

What talents, skills and gifts have you been given that could be developed to help you achieve your dream? What are you good at?

In that future you have imagined, doing the thing you love most, how do you see supporting yourself while you live that dream?

What changes do you need to make in your habits, heart, and in your thinking to turn yourself into the person who could achieve and support their dreams?

If you had six months to work on your goals while you lived at First Fruit Ministries, what would you want to accomplish in those months?

In that six months, what steps do you need to take to accomplish your goals?

We know that surviving homelessness takes a lot of work, a lot of energy. Please ask yourself, are you willing to turn the energy you spend surviving homelessness into self-discipline, and to put in the work that turning your life around would take? To work on the emotional, the mental, the physical, the spiritual, the practical? Are you willing to accept our direction, our policies, and our rules? Most importantly, are you willing to let us help you?

Yes

No

If you have questions or need help with the application you are welcome to call the office at 910.794.9656 between 10am and 2pm weekdays; we’ll be glad to talk with you

Please include with your application:

1. A proof of homelessness letter from a caseworker, therapist, shelter staff, or other professional detailing your current living situation, on letterhead, signed and dated

Upload File

2. If you are seeing a mental health professional, please ask them to attach a copy of their latest clinical or psychological assessment.

Upload File

3. A copy of your criminal history from each State where you have been convicted of a crime. You can go to the State’s Department of Correction’s website.

Upload File

Information about more than 3 children.

Upload File

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