Respite Shelter Application Form | Cardinal Community House

Full Name

Date of Birth

Contact Number

Gender

Male
Female
Non-Binary
Prefer Not to Answer

Preferred Pronouns

He/Him
She/Her
They/Them
Other

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Emergency Contact

Are you currently experiencing homelessness?

Yes
No

If Other, Please Specify

Do you currently have a safe place to stay?

Yes
No

How long have you been in your current situation?

Less than 1 week
1-4 weeks
1-3 months
Over 3 months

Do you have any medical conditions or disabilities we should be aware of?

Yes
No

If Yes, Please Specify:

Are you currently taking any medication

Yes
No

If Yes, Please Specify:

Do you have any allergies?

Yes
No

If Yes, Please Specify:

Do you require any mobility devices such as wheelchair, cane, or walker?

Yes
No

If Yes, Please Specify:

Do you require a translator?

Yes
No

If Yes, Please Specify:

Are you able to perform Personal Hygiene Independently?

Yes
No

If No, Please Specify:

Are you able to maintain a room in a tidy manner independently?

Yes
No

If No, Please Specify:

Are you able to Shower or Bath independently?

Yes
No

If No, Please Specify:

Are you able to use the restroom or toileting facilities independently?

Yes
No

If No, Please Specify:

Are you able to dress yourself independently?

Yes
No

If No, Please Specify:

Are you able to feed or eat independently?

Yes
No

If No, Please Specify:

Have you been a client at Cardinal Community House before?

Yes
No

If Yes, did you complete the full program?

If you indicated Yes, you were a client with us before, What was the reason for discharge?

What services are you seeking?

If Other, Please Specify:

Are there any active restraining orders or legal issues we should know about?

Yes
No

If Yes, Please Specify:

Have you ever been asked to leave another shelter?

Yes
No

If Yes, Please Specify:

Are you willing to follow all of Cardinal Community House's policies, protocols, and procedures?

Yes
No

Cardinal Community House maintains a zero tolerance policy for Smoking/Nicotine use in or on facility grounds including the facility, park, and parking areas. Failure to follow this procedure will result in immediate disenrollment from the program. Do you agree to not use Nicotine or Smoke anywhere on our properties?

Yes
No

Cardinal Community House maintains a zero tolerance policy for weapons to include guns, knives, sharp metal objects, baseball bats, brass knuckles, or any type of object that can be used to inflict bodily harm on our facility grounds. Weapons must be surrended at the time of arrival. Viiolation of this policy will result in immediate disenrollment from the program. Do you agree to maintain a weapon free zone?

Yes
No

Cardinal Community House maintains a zero tolerance policy for drinking alcohol or having evidence of drinking on it's facility grounds. Violation of this rule will result in immediate disenrollment from the program. Do you agree to not consume alcohol or have evidence of drinking while on facility property?

Yes
No

Cardinal Community House is mandated by State law to secure all medication in our medication room and clients within our facility must strictly follow prescription dosages while in care of Cardinal Community House. All medications including prescription medications must be stored in our secure medication room. Staff members are available around the clock to assist you with gaining access to your medications at appropriate times. Deviation from alloted times and amount will not be tolerated and will result in immediate disenrollment from the program. Do you agree to secure all medications and notify a staff member when it is time for your medication and to not exceed the prescribed limit in both time and dosage?

Yes
No

Cardinal Community House maintains a strict curfew to allow clients that are in process of healing to rest. Our facility doors are closed at 10 pm and will open at 7am. Quiet hours are to be observed during this period of time including weekends. Do you agree to maintain our curfew hours?

Yes
No

Cardinal Community House aims to provide a safe place for those in need of rest and recouperation as our primary mission. Destruction of facility property will result in immediate disenrollment from the program. Do you agree to maintain property in the same condition it was provided?

Yes
No

Cardinal Community House is a center that revolves around respect and courtesy regardless of race, gender, or sexual preferences. Do you agree to maintain a respectful and courteous environment for both clients and staff members?

Yes
No

Title VI Non-Discrimination Statement

Cardinal Community House

In accordance with Title VI of the Civil Rights Act of 1964 and all related federal civil rights laws, Cardinal Community House (CCH) ensures that no person shall, on the grounds of race, color, national origin, or limited English proficiency (LEP), be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity administered by the CCH Respite Center.

CCH also prohibits discrimination on the basis of sex, age, disability, religion, sexual orientation, gender identity, or any other characteristic protected by law, consistent with its mission of providing equitable, inclusive, and compassionate care to all individuals.

Your Rights

If you believe you have been subjected to discrimination under any CCH program or activity, you have the right to file a complaint. Complaints must be filed within 180 days of the alleged discriminatory act.

How to File a Complaint

Complaints may be filed in writing and submitted to:

Title VI Coordinator
Cardinal Community House
517 SW 2nd Street
Oklahoma City, OK 73109
Email: Thoy@cardinalcommunityhouse.com
Phone:(405) 232-0231 ext. 103

You may also file a complaint directly with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) at:
200 Independence Avenue, SW, Room 509F
Washington, DC 20201
OCRComplaint@hhs.gov | (800) 368-1019

CCH will take all complaints seriously and will not retaliate against anyone who files a discrimination complaint or participates in an investigation.

I acknowledge that I have been informed of my rights under Title VI of the Civil Rights Act of 1964, which prohibits discrimination based on race, color, or national origin in any program or activity receiving federal financial assistance.

Yes

I confirm that I have read and understand this information.

Yes

I understand that I may file a complaint if I believe I have been subjected to discrimination under Title VI.

Yes

By signing below, I confirm that the information provided is accurate and truthful to the best of my knowledge.

I understand that submitting this application does not guarantee admission to the shelter and that additional information or an intake interview may be required before I am admitted into the program.

Applications are reviewed on Monday and Wednesday of each business week. If your time of application is submitted after Wednesday, it will be reviewed on the following Monday. All applicants will be provided a notice of approval or denial to the e-mail submitted on this application.

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Title VI Non-Discrimination Statement

Cardinal Community House

Your Rights

How to File a Complaint

CONTACT US

(405) 232-0231

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