Pivotal Point Application Form

At Pivotal Point Transitional Housing we provide rent and utility free apartments for the working homeless. While staying in our fully furnished apartments you sign a written contract to participate in our transitional housing programs. The program has very rigorous educational components focusing on budgeting, life skills, community living, and case management. Please read the following very carefully and follow the instructions to apply to Pivotal Point Transitional Housing.

All participants in our 90-day Transitional Housing program must currently be maintaining 35-40 hours per week employment.
Transitional Housing program participants must be able to attend weekly sessions for life skills, case management, and budgeting. These will be scheduled around their work and school commitments.

Pivotal Point Transitional Living Program is for working singles, couples, or families staying in Buchanan County. This program is a short-term transitional program for 90-days in which participants must save or pay off debt in order to move into a home of their own. THP participants must agree by written contract to attend weekly meetings with case managers, budget counselors, and life skills coordinators. All applicants must leave a voicemail twice a week on our check-in line at (816) 689-1383 to be considered for an interview. When we have an opening available we call those who have been checking in weekly. Getting an interview does not guarantee you will be selected to move in. We are trying to determine who would be the best fit for the program and will give you next steps after the interview as to if you will be offered placement.

Full Name*

First NameLast Name

Birthdate*

Date

Social Security Number*

Highest Education Completed

Email*

example@example.com

Phone Number*

Area CodePhone Number

Current Marital Status*

Gender*

Race*

Zip code*

Are you a veteran?*

YesNo

Do you have a disabling condition?*

YesNo

Are you Hispanic?*

YesNo

Please write your name as found on social media.*

Add all who would be staying in apartment

Dependents

Are you currently enrolled in school or taking any classes? - If yes, how many hours?*

Is anyone pregnant?*

Current Address?*

How long have you lived at current address?*

Have you been asked to leave your current living situation?*

If yes, how long can you stay there?

How did you hear about our agency?*

Have you been involved with a similar program?*

YesNo

If yes, what program?

What mode of transportation do you use?*

Has anyone in the household served in the military?

Are you currently working?*

YesNo

If yes, where?

Start Date

Date

Pay Rate

How many hours a week do you work?

Previous Employers*

Income Currently Received from Job, Food Stamps, TANF, Child Support, SSI, etc.*

List all monthly expenses*

List all debts*

How many evictions do you have?*

Do you or anyone in the household have a medical diagnosis that requires ongoing treatment?

YesNo

If yes, please describe.

Do you or anyone in the household receive any medical or counseling services?

YesNo

If yes, please describe.

Do you or anyone in the household have a mental health diagnosis? Are they on medication?

YesNo

If yes, please describe.

Have you been/are you currently in counseling?

YesNo

Therapist/Program Name

Have you ever been in a mental health hospital?

YesNo

If yes, please describe.

Do you use drugs or alcohol?*

YesNo

Have you ever been to drug or alcohol rehab*

YesNo

If yes, when and where?

Name of substance/s abused:

Have you ever been arrested, if so, for what?*

Have you ever been incarcerated, if so, when and where?*

Are you on probation or parole? If so, what is the name and contact information for your probation or parole officer?*

Name any other case managers or organizations you are involved with

Are you the victim of domestic violence?*

YesNo

Please explain the reasons for your current situation*

Right to Deny Services

Name

First NameLast Name

Applicant Requirements

Transitional Housing Program