BPD Today Advocacy Program Application

Do not send this application via snail mail. Though this is a structured form, it does not have to be filled out exactly as it appears. Send the information in via email in any form you wish to the Director. For example you could say "My name is Susan Marks and I need assistance. I am 22 years old with my birth date being....and this is my home address..." etc.

Name:________________________________    Age:_____  Date of Birth_________

Street Address:_______________________________________________________

City:_______________________   State:______  Zip Code:________________

Mailing Address: (if different)

Street Address:_______________________________________________________

City:_______________________   State:______  Zip Code:__________________

County:_________________________

Phone Number (Home)__________________  (Work)_____________________

International Address (if outside the USA)

__________________________________________________________________

__________________________________________________________________

Gender:_____  Email Address__________________  Marital Status:____________

Who lives in your household and what are their ages?:_____________________________________________________________

___________________________________________________________________

___________________________________________________________________

How may we contact you? (Write "Yes" in one of these options:) Phone_____   
Email______   Mailing Address:______

Gross monthly household income: $____________

Source of Income: (Include any source of income:  SSI, SSDI, pension, unemployment, 
alimony, child support, food stamps, earned income, etc.) ___________________________________________________________________

___________________________________________________________________

Amount of Liquid Assets: (savings, checking, IRA, CDs, stocks, bonds, etc.). $_______________     Monthly Medical Expenses: $____________

Transportation: Car:___  Bus:___ Other: (please list)_________________________

Amount of Monthly Rent or Payments: $________  

Medical Insurance? Yes:____  No:____ 
Insurance Provider:____________________________________________________

Insurance Provider:____________________________________________________

Are you seeing a Dr. for your BPD?: _____  Are you seeing a therapist? _____  
Do you have a co-pay or full payment for these services?: _____________________

Are you receiving any kind assistance from any program or person?: _______ What 
are the services you are receiving?: ________________________________________

_____________________________________________________________________

_____________________________________________________________________

If you are not receiving services for your BPD, what is keeping you from it?: _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Do you have family?: Who are they?: _______________________________________

_____________________________________________________________________

Is your family supportive?: How do they help you?: ___________________________

_____________________________________________________________________

_____________________________________________________________________

Current Psychiatric and Medical Diagnoses:___________________________________

_____________________________________________________________________

_____________________________________________________________________

Are you taking any medications?: _____ If so, what are they and how do you take them?: 

_____________________________________________________________________

_____________________________________________________________________

How is your medication paid for?:___________________________________________

What type of assistance do you need?:______________________________________

______________________________________________________________________

______________________________________________________________________

Additional Information: (optional) ___________________________________________

______________________________________________________________________

Signature: __________________________________        Date: _________________

Borderline Personality Disorder Today Consumer Application - 4/03
Patty Pheil M.S.W.