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.
Applicant Requirements
1. All participants in our 90-day Transitional Housing program must be able to find and maintain 35-40 hours per week employment.
2. 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.
Transitional Housing Program
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

MonthDayYear
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?*

CarBusBikeWalkingFamily/Friends
Has anyone in the household served in the military?
Are you currently working?*

YesNo
If yes, where?
Start Date

MonthDayYear
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
Should be Empty:

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Applicant Requirements

Transitional Housing Program