Application for Social Services
Welcome to our program!
Thank you for your interest in joining our program. We are committed to supporting young adults between the ages of 18-26 who are impacted by foster care, the justice system, or homelessness. By applying to our program, you will receive mentorship, educational support, job readiness training, and mental health services to help you achieve success. Please fill out the following application form to get started. All information provided will remain confidential and will be used only for program purposes.
1. Full Name:
2. Birthday: (MM/DD/YYYY)
3. Gender:
4. Phone Number
Format: (000) 000-0000.
5. Email Address:
example@example.com
6. Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Demographic Information
(This section is used to help us understand the populations we serve and evaluate the success of our program.)
7. Race/Ethnicity:
Black/African American
Hispanic/Latino
White
Native American/Alaska Native
Asian/Pacific Islander
Other
8. Are you currently involved in any of the following?
Foster care
Justice System/Probation/Parole
Homelessness
None of the above
Other
9. Have you previously been in foster care?
Yes
No
Unsure
10. Do you Currently have stable housing?
Yes
No
Temporarily staying with others
In a shelter or transitional housing
Other
Program Participation & Goals
(this section helps us understand your needs and how we can best support you.)
11. What services are you interested in receiving from our program?
Mentorship
GED/High School Completion Assistance
Job Readiness & Workforce Development
Mental Health Services (counseling, therapy, stress management)
Housing Assistance
Educational Support (tutoring, college prep)
Other
12. Why do you want to join our program? (please provide a brief explanation of your goals and reasons for Seeking support.)
13 What are your short-term goals next 6-12 months? This can include education employment housing personal development etc.
14 What are your longterm goals 1-3 years? This can include career aspirations academic goals life goals etc.
Education & Employment History
15. Are you currently employed?
Yes
No
16. What is your highest level of education completed?
High School/GED
Some College
Associates Degree
Bachelors Degree Or Higher
None
17. Have you completed any vocational training or certifications?
*
Yes
No
If yes, please list the certifications or training completed
18. Are you currently pursuing or planning to pursue your GED or a higher level of education?
Yes
No
19. Please briefly describe your work experience or any volunteer work you’ve done:
Health & Wellness
(We offer mental health support and wellness services for young adults in need.)
20. Do you currently receive any mental health support? (Counseling, therapy, etc.)
Yes
No
21. Are you currently facing any mental health challenges?
Yes,
No
Not sure
If yes please briefly describe the challenges you are facing
22. Are you open to participating in mental health workshops or individual therapy if needed?
Yes
No
Additional Information
23. How did you hear about our program?
Referral from a friend/family member
Social media
Website
Community organization
Other
24. Is there any other additional information you would like to share or any specific needs you have??
Agreement & Signature
By signing below, I consent to my application being reviewed by the program staff and understand that providing false information may result in disqualification from the program. I also acknowledge that all personal information I have provided will remain confidential and used solely for the purpose of program participation and success evaluation.
Applicants Signature
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: