Clone of Group CLS Application

Group CLS Application
Applying for:
Name

First NameMiddle InitialLast Name
Nickname
Street address
City
State
Zip Code
County
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Medicaid #
Age
T-shirt Size
No. of Days Requesting
Days Requesting
Applicant receives support or services from (please check all that apply):

Other
Check all that apply:

Other
All documents supporting the above checked boxes must be included with this application.
School/Agency Information
List the name(s) of high school(s)/transition programs and years of attendance.

Check all that apply:

Rows	Names of High School(s), City & State	Years of Attendance
1
2

Please provide the following information about your Community Mental Health Agency
Agency
Main Phone
Format: (000) 000-0000.
Street Address
City, Zip
Caseworker(s)
Direct Phone
Format: (000) 000-0000.
Email
example@example.com
Other
Application Completed by:
Date:

MonthDayYear
Date
Title:
3250 28th Street SE, Grand Rapids, MI 49512

502 North State Steet, Big Rapids, MI 49307

616-248-3775 P | 616-419-4152 F | info@rflnetwork.org
Page 1 of 4

Family/Living Information
Applicant lives with
Parent/Guardian #1 (Primary contact)
Name

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian #2 (Secondary contact)
Name

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Group Home
Name
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

City and ZipState / Province

Postal / Zip Code
Contact #1 First and Last Name
Contact #1 Email
example@example.com
Contact #1 Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact #1 Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact #2 First and Last Name
Contact #2 Email
example@example.com
Contact #2 Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact #2 Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Statement
What do you like to do in your free time?
What is your favorite hobby or sport?
What other interests do you have?
Below, please describe some of the skills you would like or need to learn.
Independent living:
Social education:
Soft skills:
Safety training:
Please provide answers to the following questions.
Applicant likes
Applicant dislikes
Applicant's strengths and gifts
What is difficult or fearful for the applicant
Group CLS Application - Dec 2025
Page 2 of 5

Significant medical or physical conditions which may affect the applicant's participation
Medications the staff should know about
Behavioral challenges the applicant might experience
Special help required for applicant's personal needs
How does the applicant communicate his or her needs
Important information you need to know about the applicant
Volunteer Information
Has the applicant demonstrated success in volunteer experiences in the community or in the school?
Does the applicant require specialized equipment, adaptations or modifications, or specific reinforcers in the community? If so, please describe:
Behavior Information
Does the applicant demonstrate satisfactory school/prior program attendance?
If no, please explain:
Does the applicant demonstrate satisfactory behavior?
If no, please describe the nature of the applicant's behavioral challenges:
Has the applicant ever been removed from programming?
If yes, what was the nature of the offense?
How was the suspension or expulsion resolved?
Group CLS Application - Dec 2025
Page 3 of 5

Be sure to submit applicant's current IPOS and Social Work Assessment with Application. These items can be emailed to info@rflnetwork.org or uploaded on our website, www.rflnetwork.org, on the "Upload Docs" tab.
Should be Empty:

Rows	Requires complete assistance	Needs moderate assistance	Needs some assistance	Needs minimal assistance	Completely independent	?
Caring for personal hygiene and grooming needs
Dressing oneself, including zippers and shoes
Coping well with stress and anxiety
Adjusting to new situations or environments
Communicating needs in an appropriate manner
Relating to others in a socially appropriate manner
Handling conflict with another person
Respecting persons in authoritative positions
Follow verbal directions
Follow written directions
Agility, Mobility, and movement capabilities
Self-feeding
Medication Assistance

Group CLS Application