YMCA of Reading & Berks County Housing Application

B. Housing Information
What is/was your last permanent address?
How long did you live there?
Why did you leave?
What are your reasons for your housing crisis/homelessness?
Are you a resident of Berks County? If so, for how long? If no, type "no".
If no, why are you interested in living in Berks County?
Have you ever lived in the building of the YMCA of Reading?

Yes No
If so, explain
Have or do any of your relatives, friends or acquaintances live or work at the YMCA?

Yes No
If so, explain
Have you lived in any emergency shelters, transitional programs, or halfway houses previously?

Yes No
If yes, explain

C. Financial Information
Please list your income:
Have you ever applied for SSI/SSDI?

Yes No
Do you have any outstanding debts for any of the following

Utilities School Loans Fines & costs Other
If yes, please explain.

D. Education & Training
What's the highest grade you completed?
Do you have a high school diploma?

Yes No GED
Please list ALL special training courses, certificates or degrees that you have had including on-the-job training.
What do you feel was the biggest problem that you had while you were attending school?
What are your personal and career goals?
E. Military History
Have you ever been in the military?

Yes No
If yes, which branch?

I. Behavioral & Emotional Health
Have you ever been in outpatient treatment for mental health?

Yes No
Have you ever been in inpatient treatment for mental health?

Yes No
How many times?
If history of mental health treatment or counseling, what is your current diagnosis?
Who made this diagnosis and when was it made?
Describe your feeling about your mental health treatment experiences:
Have you had any thoughts, gestures, incidents, or attempts at suicide or homicide?

Yes No
If yes, explain

Please answer the following questions as thoroughly as possible.
What are the circumstances leading up to your application to the Y-Housing Program?
What has been your past reaction to authority figures?
If admitted to residency, what do you expect from the YMCA staff?
Would you be willing to meet with staff individually once a week to review the status of your goals?
How do you feel about following directions in a situation of need?
In what areas will you need help if you are accepted into the YMCA Housing Program?
What do you expect to accomplish while in residency at the YMCA? Be specific!

By signing below, I verify that the information on my application is accurate and truthful. In addition, I understand that at any time during the application and interviewing process or after acceptance into the YMCA Housing Program, if it is determined/discovered that I have lied on my application, I may become ineligible to apply or participate in the Housing Programs of the YMCA of Reading.
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YMCA of Reading & Berks County