CLP Application Revised 2/2017

CLP Application Revised 2/2017
Application for Admission for Residential CLP Services

Please complete the form below for consideration of admission to NYEP Community Living Program
Please note: NYEP is an independent living facility for youth 18 and up (under 18 from WCDSS on approval). Our agreements are made with youth and no one else. For this reason, we prefer to receive applications from and schedule interview with the youth directly. If you are referring a youth to our program, please send them the link to this application and encourage them to apply on their own if at all possible. Supportive adults are welcome to attend tours with prospective residents. Thank you for understanding.

If available, please attach the following documents or fax to 1-888-331-0717.

1. Psycological and/or Behavioral Evaluation

2. Social History and/or Behavioral Evaluation

3. Incident, police and/or court reports for the last 90 days (if applicable).
Attach file:

Name of person filling out application (if different from above):

Skip this area if filing this application out for yourself.
Name

First Name Last Name
Organization/ Relationship to Applicant:
Relationship or Organization
Phone Number

Area Code Phone Number
E-mail
Is the youth available to fill out the application on their own?

Yes No
If no, why?

Youth is incarerated Youth is hospitalized Youth has no access to the internet; Please have youth call Jeanine at (775) 200-4030 to set up a tour. Other
If incarcerated; where/ what charges?:
Expected release date:
If hospitalized; wherereason for hospitalization:
Expected discharged date:
If other; specify:

Refferal information: (List the contact that reffered you to our program, if applicable)
Referral Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
E-mail
Alternative Contact Information: (This information is being collected to assist us in locating you in the event that you move or are living temporarily in another location. List contact that is heling you through this process, if applicable.)
Alternative Contact Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
E-mail
Emergency Contact Information
Emergency Contact Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
E-mail

PERSONAL GOALS
What do you feel that we can help you with?

Housing Employment Education
What are your educational goals and how do you think our program could help you achieve them?
What are your employment goals and how do you think our program could help you achieve them?
Are you willing to participate in a certificate or workforce development program?

Yes No
How would you describe yourself?
Please describe how you believe that our program could help you reach your short and long term goals?
What are your greatest strengths that would help you be successful in our program?
What are some things that are getting in the way of your goals and/or challenges?

I hereby authorize NYEP to receive information regarding my application and further authorize relevent outside parties to exchange and release personal records regarding my application with NYEP's Housing Manager.
I understand that I am requesting to participate in NYEP's CLP Program, which is a gender inclusive housing program. I understand that I am agreeing to live in the same room with any other resident regardless of biological gender.
I understand that false statements or information are cause for non-acceptance to NYEP's CLP Program.
Applicant Signature

Clear
Date

Month Day Year
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Application for Admission for Residential CLP Services