• 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).

     

  • GENERAL INFORMATION 

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

    Skip this area if filing this application out for yourself. 

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  • Refferal information: (List the contact that reffered you to our program, if applicable)

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  • 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.)

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  • Emergency Contact Information

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  • WELLNESS

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  • Please list all prescription medication that you take.

  • SUBSTANCE ABUSE

  • EDUCATION, EMPLOYMENT & VOLUNTEER HISTORY



  • PERSONAL GOALS


  • WILLINGNESS

  • Clear
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  • Reload
  • Should be Empty: