Application

Application

Please complete the information and one of our intake personnel will be giving you a call from our toll free number.
Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number*
Work Number*
Preferred Method of Contact*
Emergency Contact (Name & Phone)
SAFETY & IMMEDIATE NEEDS
Are you currently in a safe environment?

YESNOUnsure
Do you currently need housing or a safe place to stay?

YESNOWithin the next 30 days
Are you fleeing from or recovering from: (check all that apply)

Domestic ViolenceSexual AssaultHuman traffickingEmotional/financial abuseOther (please describe below)
Please give details. The date the incident, were there weapons involved, if charges was pressed.
Do you have any immediate safety concerns we should know about?

YesNo
Please explain (optional)
CURRENTLY LIFE STABILITY

Please check all that apply to you right now.
Housing Status:

Stable HousingStaying with family/friendsShelter or transitional housingAt risk of homelessnessCurrently unhoused
Employment Status:

Employed Full-TimeEmployed part-timeSelf-Employed / Business OwnerUnemployedSeeking employment
Education Status:

High School Diploma or GEDSome College/ Technical TrainingAssociatesBachelorsMasters or PHDCurrently Enrolle
SECTION 4: HEALING & WELLNESS READINESS
Are you currently receiving counseling or mental health support?

YesNo
How would you describe your emotional wellness right now?

StableManaging but OverwhelmedIn need of supportIn Crisis
Are you open to participating in:

Support Groups in personWellness & Healing WorkshopSupport Groups onlineJournaling or reflective activities
SECTION 5: FINANCIAL & LIFE SKILLS
Check areas where you would like support:
Check areas where you would like support:

Budgeting & money managementDebt ManagementSaving MoneyLife Skills (Cooking. Time Management, Wellness, Self Care, Healthy Lifestyle)
SECTION 6: CAREER & WORKFORCE INTERESTS
Are you interested in employment or career advancement?

YesNoNot at this time
Would you benefit from:

Resume and interview supportJob certifications (OSHA, CPR, ServSafe)Job placement assistanceWork clothing or transportation
What type of work are you interested in (if known)?
SECTION 7: ENTREPRENEURSHIP & BUSINESS INTEREST
Do you currently own or want to start a business

Yes I own a businessYes I want to start a businessExploringNo
Are you interested in:

Business TrainingMentorshipPitch OpportunitiesBusiness and Nonprofit Compliance
SECTION 8: LEADERSHIP & ADVOCACY INTEREST
Are you interested in leadership, mentoring, or advocacy?

YesNo
Would you like training in:

Public SpeakingPeer MentorshipCommunity Advocacy
SECTION 9: TRANSPORTATION NEEDS
Do you currently need assistance with transportation for:

WorkSchoolInterviewCourt
SECTION 10: PROGRAM INTEREST (OPTIONAL)Check any programs you are interested in (staff will confirm final placement):

Rise and Renew Healing JourneyCareer Catalyst ProgramFounders Flight Startup AcceleratorMoney Mastery for SurvivorsTrailblazer Leadership AcademyPathway Transport ProgramSWAT Virtual SanctuaryNo Judgement Zone (Women Only)Safeguard ProgramHaven of Hope Residential Program (Currently Unavailable)Healthy LyfestyleCommunity Impact & Awareness Initiative
SECTION 11: AVAILABILITY & PARTICIPATION
Are you able to commit to weekly program participation?

YesNoDepend on Schedule
SECTION 12: FINAL QUESTIONS
What are your top 3 goals right now?
What does stability look like for you in the next 6–12 months?
Is there anything else you would like us to know?
SECTION 13: CONSENT & ACKNOWLEDGMENT
I certify that the information provided is true to the best of my knowledge. I understand that program placement is based on eligibility, readiness, and availability. I consent to be contacted by SWAT regarding services and referrals. The applicant needing assisting please upload your ID. If you need assistance with housing, please include your child(ren) 's information. Please upload.

Cancelof
Should be Empty:

Application

SECTION 6: CAREER & WORKFORCE INTERESTS

SECTION 7: ENTREPRENEURSHIP & BUSINESS INTEREST

SECTION 8: LEADERSHIP & ADVOCACY INTEREST

SECTION 9: TRANSPORTATION NEEDS

SECTION 11: AVAILABILITY & PARTICIPATION

SECTION 12: FINAL QUESTIONS

SECTION 13: CONSENT & ACKNOWLEDGMENT