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Step 1 of 10 - General

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General Information
Which program are you applying for?*
Name*
First Last
Primary Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
- Male
- Female
Ethnicity*
- African American/Black
- American Indian/Alaskan Native
- Asian
- Caucasian
- Hawaiian/Pacific Islander
- Hispanic
- Italian
- Two or more races
Date of Birth*
MM slash DD slash YYYY
Age*
Primary Phone Number*
Secondary Phone Number
Work Phone Number
Email*
Primary Language*
Last 4 digits Social Security #
ID / Driver's Lic #
Are you a legal US Citizen?*
- Yes
- No
Other Citizenship Status*
- Legal Resident
- In Process
- Undocumented
Marital Status*
- Single
- Married
- Divorced
- Widowed
Do you have children?*
- Yes
- No
How many children?*
Children Ages*
eg. 4, 7, 12
Living Situation*
- Homeless
- Family
- Shelter
- Friends
Did you age-out of foster care?*
- Yes
- No
Age-out Date*
MM slash DD slash YYYY
Have you ever served on active duty in the U.S. military?*
- Yes
- No
What is your U.S. military discharge status?*

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Emergency Contact Information
Emergency Contact Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number*
eg. Home or Cell
Secondary Phone Number
eg. Work or

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Referral / Agency Source
Name of the person who referred you to our program.*
Relationship*
Agency
Phone Number
Email

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Education
Check Highest Grade Completed*
- Elementary 5
- Elementary 6
- Junior High 7
- Junior High 8
- High School 9
- High School 10
- High School 11
- High School 12
Last School Attended*
Do you have an Individual Education Plan?*
- Yes
- No
Do you possess one of the following*
- High School Diploma
- GED
Last College / Trade School Attended
Units Completed

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Employment / Financial Information
Are you currently employed?*
- Yes
- No
Work Schedule*
- Full Time
- Part Time
How many hours per week do you work?*
Name of Employer*
Work Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor Name*
Supervisor Phone Number*
Date Hired*
MM slash DD slash YYYY
Salary*
eg. xx/hr or xx/month
Job Title*
Description of Job Duties*
What is your primary source of income?*
- General Relief
- Social Security Insurance
- No Income
Do you have a checking account?*
- Yes
- No
Do you have a savings account?*
- Yes
- No

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Medical History
What type of medical insurance do you have?*
- Medi-Cal
- Private Insurance
- None
Doctor's Name
Doctor's Phone Number
Dentist's Phone Number
Dentist's Name
Please list any medical conditions, past or present.
Have you ever been hospitalized?*
- Yes
- No
Hospitalization Details*
Please list any prescribed medications you are currently taking.
Do you drink alcohol?*
- Yes
- No
How often do you drink alcohol?*
- Daily
- Weekly
- Monthly
- Occasionally
Do you currently use drugs?*
- Yes
- No
How often do you use drugs?*
- Daily
- Weekly
- Monthly
- Occasionally
What types of drugs are you currently using?*
Do you smoke cigarettes?*
- Yes
- No

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Mental Health History
Do you have any mental and/or emotional health problems?*
- Yes
- No
Explain your mental and/or emotional health problems.*
Have you ever been diagnosed and/or treated for mental or emotional health problems?*
- Yes
- No
Explain your mental or emotional health diagnosis.*
Are you taking medication related to mental heath?*
- Yes
- No
List any mental heath medication you are taking.*
Are you prescribed medication related to mental health that you cannot afford?*
- Yes
- No
Explain your mental health prescription cost limitations.*
Are you prescribed medication related to mental health that you are NOT taking*
- Yes
- No
Explain why you are NOT taking your medications.*

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Legal / Gang History
Have you ever been arrested?*
- Yes
- No
How many times?*
Describe the details of your arrests.*
Have you ever been incarcerated?*
- Yes
- No
How many times?*
What are the details and lengths of your incarceration(s)?*
Are you currently on probation?*
- Yes
- No
Probation Officer Name*
Probation Officer Phone Number*
Please explain the nature of the incident(s) that led to your probation.*
Have you ever been on probation in the past?*
- Yes
- No
Age on Probation*
- Juvenile
- Adult
Please explain the nature of the incident(s) that led to your past probation.**
Have you ever been convicted of a sex crime?*
- Yes
- No
Are you a Registered Sex Offender?*
- Yes
- No
- Prefer Not to Say
Are you court ordered here to the Dream Center?*
- Yes
- No
Give contact information regarding your court case.*
Do you have any legal charges pending?*
- Yes
- No
Do you think you have any outstanding warrants?*
- Yes
- No
Are you now or were you ever affiliated with a gang?*
- Yes. I am currently in a gang.
- No. I have never been in a gang.
- I was previously in a gang but am no longer.
Name of Gang*
Do you have an open case with the Department of Children and Family Services?*
- Yes
- No

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Spiritual Information
How would you describe yourself spiritually?*
- Christian
- Catholic
- Atheist
- Agnostic
Do you regularly attend a church service?*
- Yes
- No
Name of Church*
City*
Church Denomination*
How long have you attended this church?*
*While we don’t require applicants to our program to be “Christian”, we are a faith-based program and facility with rules and policies that reflect that belief system.

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Signature and Acknowledgments
I CERTIFY THAT THE INFORMATION I HAVE COMPLETED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
**This application and supporting documentation/information is privileged and confidential. Distribution and/or reproduction of any record or information outside the intended and approved use is strictly prohibited. Illegal or misuse of this information is punishable by fine and/or imprisonment.
Applicant Signature*
Please sign using your mouse or touch device.
Email
This field is for validation purposes and should be left unchanged.

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2301 Bellevue Ave.
Los Angeles, CA 90026

Email: [email protected]
General Office: (213) 273-7000
Donation Support: (213) 273-7100

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