Transitional Living Program Application

Transitional Living Program

Application
Legal Name*

First NameMiddle NameLast Name
Do you go by any other names?

YesNo
If yes, please enter other name(s) below:
Gender*
Pronouns*
Age*
We are unable to accept anyone under the age of 16 or above the age of 21
Date of Birth*

MonthDayYear
Date
Birthplace City and State*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Alternate Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Current Status*

HomelessAt-risk of HomelessnessRunawayPotential RunawayProbationCourt WardEmancipatedNone of the Above
Most Recent Living Situation, Please check one*

Legal GuardianNon-Custodial ParentRelative's HouseFriend's HouseFoster HomeGroup HomeDrug Treatment CenterLiving IndependantlyPsychiatric HospitalShelterResidential ProgramCorrection/Detention CenterRunawayOther
BACKGROUND INFORMATION
Parent/Legal Guardian*

First NameLast Name
Their Place of Residence *
Parent/Legal Guardian *

First NameLast Name
Their Place of Residence *
If under 18, are you legally emancipated?*

YesNo
If yes, date of emancipation
Do you have children?*

YesNo
If yes, please share their name(s), sex, date of birth(s), and if you have custody
Are you currently pregnant?*

YesNo
If yes, what is your due date?

MonthDayYear
Date
Do you have any piercings or tattoos?*

YesNo
If yes, please describe
LEGAL HISTORY
Have you been arrested or in trouble with the law?*

YesNo
If yes, please describe
Do you have any charges pending?*

YesNo
If yes, please describe
Do you have any upcoming court dates?*

YesNo
If yes, please describe
Are you currently on probation or parole?*

YesNo
If yes, please describe
Are there any outstanding pick-up orders or warrants for your arrest?*

YesNo
If yes, please describe
Are you AWOL from a court-ordered placement or not in contact with your worker?*

YesNo
If yes, please explain
Have you ever been charged with criminal sexual conduct?*

YesNo
If yes, please explain
RESIDENTAL HISTORY
Please list any residential programs you have been in, starting with the most recent. Please also list date you were in program. *
Have you been in Foster Care?*

YesNo
If yes, please describe reason for placement and dates
Are you currently involved in an open CPS case?*

YesNo
If yes, please describe
Have you been in any type of long-term living situation other than with your parents/guardian or the situations described above?*

YesNo
If yes, please describe
EDUCATION
Please mark all that describes your school situation*

Graduated High SchoolCompleted GEDAttending school regularlyAttending school irregualrySuspendedDropped outSchool not in sessionExtended truancyExpelledOther
Please list the name(s) and dates of the schools you have attended*
MEDICAL AND MENTAL HEALTH HISTORY
Please list any current medical and/or mental health issues/concerns/diagnoses*
Please list any medications you are currently taking*
Please list any medications you have taken in the past*
Have you ever been hospitalized for mental health concerns?*

YesNo
If yes, please list the name of hospital(s), reason, and dates
Have you ever in counseling or outpatient therapy (current and/or past)?*

YesNo
If yes, please list the counselor/therapist, agency, and dates
SUBSTANCE USE HISTORY
Are you concerned about your substance use?*

YesNoUnsure
Have you ever tried to cut back on your use?*

YesNoUnsure
Have you ever been annoyed when questioned about your use?*

YesNoUnsure
Have you ever felt guilty about your use?*

YesNoUnsure
Have you ever had an "eye-opener" to get you started in the morning?*

YesNoUnsure
Please list any substance you have used in the last six months and at what frequency. *
Have you ever been in drug treatment?*

YesNo
If yes, please list the name of the agency/program and that dates
Do you agree to not using ANY substance, including vapes and regardless of age, while on FYI premises?*

YesNo
EMPLOYMENT/FINANCIAL HISTORY
Are you currently employed?*

YesNo
If yes, where, for how long, and how many hours
If no, are you willing to seek employment?*

YesNoN/A
If you are not willing to work, please explain why and what you plan do to instead of working?
Please list any previous employment/job training you have participated in, including dates*
Do you and/or your parent/guardian receive any other income such as DHHS benefits (food stamps, cash assistance, etc.), SSI, adoption subsidies, etc.?*

YesNo
If yes, please list income source and the Representative Payee for each
PERSONAL STATEMENTS

Entering Family Youth Interventions' Transitional Living Program is a commitment to making changes in your life. The following personal statements will help us determine your willingness to make those changes. Please make your statements AT LEAST 25 WORDS in length.
FYI provides a stable, semi-independent living situation for young people who do not have other options for a place to live. Please describe your current situation and how it developed. *
If you are accepted, we will provide you with a stable place to live while you work on creating your own independent living situation. Please describe A) What your future plans are B) How living her fits in with those plans C) What you plan to do while you are here D) How long you will need to live here*
If accepted, you will be living in a house with other residents (of all genders), 24 hour adult staff, frequent visits by former residents and guests, and - at times- small children. Please idenfiy any problems you may have adjusting to a group living setting, and how you resolve conflicts with people. *
REFERNCES

Please provide three references that can provide information regarding your ability to get along with others, readiness for independent living, work/school performance, etc.
Please read and sign below

I authorize Family Youth Interventions to make inquiries of identified references. Although I recognize that these individuals and entities may have a general policy to disclose only specific, limited information, I authorize all past and current employers, educational institutions and all other individuals providing references to depart from that policy. I authorize these individuals and entities to respond to verbal and written inquiries from Family Youth Interventions regarding my past employment, verification of my educational background, my performance, and my personal character. I hereby release Family Youth Interventions and all such persons and entities providing information from any liability and damages incurred as a result of furnishing this information.
Name - Professional Reference (supervisor, teacher, counselor, case worker, past placement, etc.)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name - Personal Reference *Must be an adult (family, neighbor, clergy, mentor, etc.)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name - Additional Reference *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
By entering your name you agree Family Youth Interventions staff may contact your references and that, to the best of your knowledge, the information you shared in this application is correct. *
Date

MonthDayYear
Date
Should be Empty:

Transitional Living Program

BACKGROUND INFORMATION

LEGAL HISTORY

RESIDENTAL HISTORY

EDUCATION

MEDICAL AND MENTAL HEALTH HISTORY

SUBSTANCE USE HISTORY

EMPLOYMENT/FINANCIAL HISTORY

PERSONAL STATEMENTS

REFERNCES