Young Adult Residential Application

YOUNG ADULT RESIDENTIAL APPLICATION

Thank you for applying to The Faine House
The Faine House welcomes your application for residency at our safe and secure facility located in Orlando, Florida, where our mission is young adult independence and stability. The following questions help us get to know you and discern whether our program can assist you in reaching your goals.
Name: *

First NameLast Name
US Citizen?*

YesNo
Gender:*
Date of Birth:*
Social Security Number: *
Phone Number: *
Email: *
Describe Current Living Situation*
Young Adult's Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Status (Check One)*

EFC/PESSFoster History (Not EFC/PESS)Unaccompanied/Homeless YouthOther
RISE ASSESSMENT
RESILIENCE: Describe a challenge you have overcome and how you handled it?*
INDEPENDENCE: What goals do you have for independent living?*
STABILITY: What barriers or challenges are you currently facing?*
EMPOWERMENT: What personal strengths or support systems help you move forward?*
Education & Employment
Currently enrolled in school?*

YesNo
Highest Level of Education Completed*
Do you have a resume?*

YesNo
Current Employment Status*
What are your career interests or goals? *
PROGRAM NEEDS
Housing Support*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Employment Assistance*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Education Support*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Life Skills Coaching*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Mental Health Resources*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Transportation Assistance*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Financial Literacy*

1

2

3

4

5

1 is Don't Need, 5 is Urgent
Is there anything else you would like us to know? *
PROGRAM REQUIREMENTS
Are you aware, The Faine House is a 1-2 year program with expectations and requirements? *

YesNo
Are you aware there will be curfew, drugs, alcohol, visitor, and leaving grounds policies (that will be explained should you receive an interview)? *

YesNo
Are you aware the application process may take a few weeks and we do not accept every applicant? *

YesNo
Are you committed to developing healthy boundries, relationships, disciplines, and habits in your own life - in regards to your employment, education, and finances? *

YesNo
How do you see The Faine House program assisting you to achieve your short- and long-term goals? *
What are your goals, and how do you see yourself accomplishing those within the next 2 years? *
Do you understand this is a program that you are required to work through, and we are not emergency housing or like other traditional group homes? *

YesNo
Do you understand that there are daily, weekly, monthly & yearly expectations for you to meet? *

YesNo
Are you committed to staying at The Faine House for 2 years? This is a program requirement.*

YesNo
Are you committed to working towards full financial independence - a life without dependence on government subsidies?*

YesNo
Do you understand that if you have a previous history of a violent and/or sexual abuse crime or commit one while in The Faine House, you will be disqualified from The Faine House program?*

YesNo
Are you committed to working with mentors and referred services? *

YesNo
Have you ever lived in transitional housing? *

YesNo
REFERRAL SOURCE
If applicable, Referral Source - Agency Name:
Referral Source Contact:

First NameLast Name
Referral Source Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source Email:
example@example.com
Caseworker name (if applicable)
Do You Authorize the Release of Your Juvenile Case Management Records to The Faine House, Inc.?*

YesNoI do not have a caseworker or previous case files
Caseworker Phone Number:
BACKGROUND/HISTORY
Do you currently receive SNAP benefits?*

YesNo
If so, amount you receive:
Do you currently use drugs?*

YesNo
If yes, what types of drugs do you use?
Frequency:
Date of last use:

MonthDayYear
Date
Have you been hospitalized due to drugs or alcohol - this includes for an accident caused by drugs that you or someone else was taking at the time?*

YesNo
If yes, please explain:
If it was an overdose, which substance?
What was the treatment required?
Have you ever been arrested?*

YesNo
If yes, list charges:
Were you convicted?

YesNo
Have you ever been in jail or a detention home?

YesNo
If yes, when & where?
Have you ever been adjudicated delinquent?

YesNo
If so, in what county and state?
Probation Officer:

First NameLast Name
Probation Officer's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
How long is your probation period?
Are you required to complete community service hours?

YesNo
If yes, how many hours?
Any other conditions of the probation?
Date probation was completed:

MonthDayYear
Date
Additional court obligations (fines, letters, etc.):
Have you ever had a psych evaluation? *

YesNo
If yes, when?
Have you recently experienced suicidal thoughts? *

YesNo
If yes, did/do you a plan to carry out suicide?
Have you ever thought of hurting yourself?*

YesNo
Have you ever been diagnosed with a depressive disorder?*

YesNo
Do you have special medical needs?*

YesNo
If so, please explain:
Medical Diagnosis - physical or mental:
Primary Care Physician:
Primary Care Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any known allergies?*
Are you on any medications?*

YesNo
If so, name & frequency/dose:
Have you ever seen a Psychiatrist or Mental Health Therapist?*

YesNo
If so, what's your Psychiatrist/Psychologist Name?
Have you been hospitalized and/or admitted to a residential treatment facility?

YesNo
If applicable, date you entered foster care:

MonthDayYear
Date
Reason for removal from biological home:
Do you have any reliable mentors/supporters in your life - church leaders, relatives, teachers, case managers, GAL, adult friends, etc.?*

YesNo
If yes, what are your mentor's name(s)?
Do you have an emergency contact?*

YesNo
If yes, can you provide name & number:
Do you practice a religion?*

YesNo
If so, what religion & where do you practice?
Do you have a close, reliable friend your age?*

YesNo
If so, where do you know them from?
Where does he/she live?
Young Adult Printed Name:*
Today's Date*

MonthDayYear
Date
I agree that I have completed this application in its entirety & in truth to the best of knowledge. I understand that dishonesty can hinder my approval.*
Should be Empty:

YOUNG ADULT RESIDENTIAL APPLICATION

RISE ASSESSMENT

Education & Employment

PROGRAM NEEDS

PROGRAM REQUIREMENTS

REFERRAL SOURCE

BACKGROUND/HISTORY