Pivotal Point Application Form

At the Young Adult Pivotal Point Transitional Housing program we provide rent and
utility free apartments for homeless youth ages 17-22 who are attending school and
working part-time or working full-time. While staying in our fully furnished apartments
you sign a written contract to participate in our transitional housing programs. The
Young Adults program has very rigorous educational components focusing on
completing High School or GED, pursuit of career through training or college courses,
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 either be in
school and working 15-20 hours or be able to find and maintain 35-40 hours per
week of 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.

The Young Adult Pivotal Point Transitional Living Program is for working singles,
couples, or families staying in Buchanan County. This program is a longer transitional
program that is approximately 18-24 months in length in which participants must be
attending school and working part-time or working full-time and working to save and
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 Name Last Name

Birthdate

Date

Social Security Number *

Highest Education Completed

Email *

example@example.com

Phone Number *

Area Code Phone Number

Current Marital Status *

Gender *

Race *

Zip code *

Are you a Veteran *

Yes No

Do you have a disabling condition? *

Yes No

Are you Hispanic? *

Yes No

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 can you stay there?

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? *

Yes No

If yes, what program?

What mode of transportation do you use? *

Car Bus Bike Walking Family/Friends

Has anyone in the household served in the military?

Are you currently working? *

Yes No

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 receive any medical or counseling services?

Do you use drugs or alcohol? *

Yes No

Have you ever been to drug or alcohol rehab *

Yes No

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? *

Yes No

Please explain the reasons for your current situation *

Right to Deny Services

Applicant Requirements

Transitional Housing Program