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
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Preferred Method of Contact
Emergency Contact (Name & Phone)
SAFETY & IMMEDIATE NEEDS
Are you currently in a safe environment?
Do you currently need housing or a safe place to stay?
Are you fleeing from or recovering from: (check all that apply)
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?
Please explain (optional)
CURRENTLY LIFE STABILITY

Please check all that apply to you right now.
Housing Status:
Employment Status:
Education Status:
SECTION 4: HEALING & WELLNESS READINESS
Are you currently receiving counseling or mental health support?
How would you describe your emotional wellness right now?
Are you open to participating in:
SECTION 5: FINANCIAL & LIFE SKILLS
Check areas where you would like support:
Check areas where you would like support:
SECTION 6: CAREER & WORKFORCE INTERESTS
Are you interested in employment or career advancement?
Would you benefit from:
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
Are you interested in:
SECTION 8: LEADERSHIP & ADVOCACY INTEREST
Are you interested in leadership, mentoring, or advocacy?
Would you like training in:
SECTION 9: TRANSPORTATION NEEDS
Do you currently need assistance with transportation for:
SECTION 10: PROGRAM INTEREST (OPTIONAL)Check any programs you are interested in (staff will confirm final placement):
SECTION 11: AVAILABILITY & PARTICIPATION
Are you able to commit to weekly program participation?
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.

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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