Dream Chasers Housing Program Application

Dream Chasers Transitional Housing Program

Residential Application
Thank you for completing this application. The Dream Chasers Housing Program is established to provide a safe, stable, affordable, and comfortable home environment. Please understand that our program requires a commitment to be independent, employed, and/or attend college, and develop life skills. We accept persons who can care for themselves and desire a better life. You must have a stable source of monthly income to pay for your program fees, food, and personal items. All residents are expected to be respectful of one another and to participate in weekly chores and activities.
Today's Date:
Name*

First Name:Middle Name:Last Name:
Previous Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:*
Please enter a valid phone number.
Is this a cell phone number?*

YesNo
Email Address*
Best Method of Contact*
Best Method of Contact*

TextEmailPhone Call
Marital Status:*

SingleMarriedDivorcedSeparated
Veteran Status:*

I am a veteran of the United States Armed ForcesI am an active duty member of the United States Armed ForcesI am a member of the National Guard or ReservesNone of the above
Are you a former foster youth?*

YesNoOther
YesNoOther
Date of Birth:*

MonthDayYear
Date
Current Age:
Do you have children?

YesNo
If yes, how many ?
Number of Immediate Family Member:
Race*

Native American or Alaska NativeAsianBlack or African AmericanWhite/CaucasianUnknownOther
Ethnicity*
Gender*
Spoken Language:
Vocational/Educational Information
Education Level:*

Jr HighHigh SchoolGEDCollegeTrade SchoolJob CorpCurrently Attending College or Trade SchoolSeeking GED
Please provide the name of the college/trade school you are attending if applicable (put N/A if you are not in school)*
Income Status:*

Work Part-timeWork Full-timeSupplemental Security Income (SSI) or Social Security Disability Income (SSDI)General ReliefCollege FundsSupervised Independent Living Placement (SILP)Other
How much is your monthly income?*
Do you currently have any barriers that may affect your ability to pay program fees on the first of each month?*
If you are currently employed, please provide employer information below:
Place of Employment (put N/A of you are unemployed)*
Name of Supervisor/Manager*
Please enter a valid phone number.
Name of Supervisor/Manager

First NameLast Name
Please provide your typical weekly schedule, including activities like work and school
Supervisor's Contact Number*
Please enter a valid phone number.
Transportation
What is your method of transportation?*

Public transportationPersonal vehicleShared vehicle with familyRide share service (Uber/Lyft)Other
Do you have a Driver's License?*
Do you have car insurance?*

YesNoNot Applicable
Housing History
Where you lived the last 12 months. Check all that applies.*

Non-housing (street, car, park)Motel/HotelEmergency ShelterTransition HousingMental Health FacilitySubstance Abuse Treatment FacilityMental Health FacilityHospital/Nursing CenterPrison/JailDomestic Violence ShelterHomeless ShelterLiving with a friend /familyRental HouseRental ApartmentOther
Please explain why you are need housing at this time:*
If accepted to live into the Dream Chasers Housing Program, you will be sharing living space with others of the same gender.

Please answer yes or no.
You are responsible for cleaning after yourself in all spaces on the premises, inside and out. The kitchen and bathroom area must be cleaned after use by residents. Are you able to do so?

YesNo
Can you purchase and cook your own food?

YesNo
Can you get along with roommates?

YesNo
Can you share cleaning the outside?

YesNo
How do you prefer to communicate about household issues?

In personText/ChatHouse Meetings
Do you prefer a quiet or social living environment?

QuietSocial
How do you settle disputes or conflicts? *
What are your hobbies or interests?
What are your expectations for a housemate?
How did you hear about the Dream Chaser Housing Program?

DCFSGuardian ScholarsNext-UpNPLA WebsiteOther
INTAKE QUESTIONS

Prior housing situation. Check reasons for leaving last housing situation.
Eviction due to unpaid rentEviction for reason other than unpaid rentConflict with friends or familyOvercrowdingDomestic violenceHospitalization, including long term treatmentHousing condemmedFireNot ApplicableOther
Explain:*
Mental Health History:
Check all that apply. Have you had in the past or currently experience any of the following:*

Assaultive behaviorDelusionsSevere depressionSevere thoughts disorderCognitive impairmentSuicidal thoughts/ideasSuicidal attemptsHallucinationsArson/fire settingVictim of Sexual abuse/assaultVictim of TraumaHoardingBi-PolarSchizophreniaNoneOther
If other, please specify:*

Are you currently or ever have been diagnosed with any of the following?*

	Yes	No	Currently
Mental Illness
Alcohol Abuse
Drug Abuse
HIV/AIDS and related diseases
Developmental disability
Physical disability

Physical Health History
Do you have health insurance?

YesNo
Company Name:
Do you have healthcare provider?

YesNo
Name of provider:
Company Name:
Do you use public health providers?

YesNo
Are you currently under doctor’s care?

YesNo
If yes, please explain:
Where do you go to get your health service (Location)?
When was your last physical examination?

MonthDayYear
Date
Do you have dental insurance?

YesNo
Name of Provider:
Have you been hospitalized in the last 12 months?*

YesNo
If yes, please explain:
Are you currently seeing a mental health professional (i.e. therapist, psychologist, etc.)?*

YesNo
If yes, please explain (Use N/A is you are not currently seeing a mental health professional):*
Where do you receive mental health services? (Use N/A if you are not currently receiving mental health services)*
Are you taking any medication?*

YesNo
If yes,

FrequentlyDailyWeeklyMonthly
List the medications that you are currently taking (Use N/A if you are not currently taking medication): *
Are you diabetic and require daily testing and/or insulin shots?*

YesNo
Physical Health Status:
Do you have long term illness?*

YesNo
If yes, please explain
Do you have short-term illness?

YesNo
If yes, please explain
Do you have physical limitations?

YesNo
Does your physical limitation require continuous care?

YesNo
If yes, please explain
Does your physical limitation require continuous care?

YesNo
If yes, please explain
Does your vision limitation require continuous care?

YesNo
If yes, please explain
Do you need help with your daily routine or health care routine?

YesNo
If yes, please explain
Check the health problem you currently have.*

AsthmaHigh Blood PressureStomach ProblemsThyroid ProblemJoint ProblemBack PainSevere Head AchesEpilepsy /SeizureDepressionEmotional ProblemDiabeticNot ApplicableOther
Disabled, if so, please verify with documentation

Cancelof
Please upload your most recent DCFS Court Report or Foster Care Verification Letter*

Cancelof
You will need to undergo a background check; please indicate your consent.

YesNo
I have answered all questions to best of my ability. I understand this application will be used to determine if I will be accepted into the Nehemiah ProjectLA Dream Chasers Program. I understand that completion of this application does not guarantee acceptance into the program. I also understand that once my application has been reviewed and approved, I will be asked to participate in a live interview (either in-person or by Zoom) to finalize my acceptance into the program. I have read and understand the conditions of this application and authorize Nehemiah Project LA, Inc. to use the information that I have provided to determine my eligibility in their transitional supportive housing program.
Print Name:*
Signature*

Clear
Date*

MonthDayYear
Date
Comments:
Should be Empty:

Dream Chasers Transitional Housing Program