Pivotal Point Application Form

At the Young Adult Pivotal Point Transitional Housing program we provide rent and
utility free apartments for homeless youth ages 17-20 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.
Applicant Requirements
1. All participants in our 12-24 month 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.
Transitional Housing Program
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 816-205-4879 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*
What is the highest grade level you have 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.*
Are you currently enrolled in school or taking any classes? - If yes, how many hours*
Are you or your partner 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?*

Drive CarRide Public BussBikeUber/LyftRide with Friends/Co-WorkersWalkOther
Do you have a driver's license or permit?*

YesNo
Do you have your own car?*

YesNo
Have you ever served in the military? If yes, what program? Why did you leave?
Have you ever been in foster care? When and how long were you in foster care?
Can you tell us how the last 6 months have been for you?
Why are you seeking out a transitional housing program?
Describe your family and friends: Who do you get along with or not get along with and why?
Do you or did you have an IEP?

YesNo
What challenges have you had in school?
What are your immediate and long-term goals for education?
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 have a medical diagnosis that requires ongoing treatment? If yes, please describe:
Do you receive any medical or counseling services? If yes, please describe:
What is the name of the doctor/medical clinic you have visited for medical concerns?
Do you have a mental health diagnosis? Are you on medication? 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? Which hospital were you in? Dates and how long did you stay?
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? When and why were you arrested?
What was the outcome of your arrest?
Have you ever served time in jail/prison? If yes, please explain.
Do you have any outstanding tickets or warrants? Please explain.
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*
List three things you like about yourself.
List three things about yourself you want to improve.
If you were living with a roommate, and they stole a piece of clothing from you, how would you react? if you felt angry, what would you do?
If you were hanging out with a group of people and someone offered you a joint, how would you handle that if you didn't want to smoke? Would it be hard to handle this situation?
There are rules in everyday life that we are asked to follow. When a rule is broken, often a person in authority has to address the broken rule. How do you react in those kinds of situations? How does it make you feel? What is your first instinct when you have to interact with an authority figure?
What do you do with your free time? What are your hobbies?
What do you do when you are alone?
What are your plans for the future?
Please rate your ability to handle the following skills:
Wake up on your own:

Extremely PoorPoorFairGoodExcellent
Household Chores:

Extremely PoorPoorFairGoodExcellent
Hygiene:

Extremely PoorPoorFairGoodExcellent
Laundry:

Extremely PoorPoorFairGoodExcellent
Being on time:

Extremely PoorPoorFairGoodExcellent
Getting along with others:

Extremely PoorPoorFairGoodExcellent
Purchase food:

Extremely PoorPoorFairGoodExcellent
Budget Money:

Extremely PoorPoorFairGoodExcellent
Prepare well-balanced meals:

Extremely PoorPoorFairGoodExcellent
Purchase clothing:

Extremely PoorPoorFairGoodExcellent
Use a bank:

Extremely PoorPoorFairGoodExcellent
Find a job:

Extremely PoorPoorFairGoodExcellent
Keep a job:

Extremely PoorPoorFairGoodExcellent
Use public transportation:

Extremely PoorPoorFairGoodExcellent
Use a hospital:

Extremely PoorPoorFairGoodExcellent
Use a library:

Extremely PoorPoorFairGoodExcellent
Knowledge of colleges, trade or vocational schools:

Extremely PoorPoorFairGoodExcellent
Use a computer:

Extremely PoorPoorFairGoodExcellent
Use a phone:

Extremely PoorPoorFairGoodExcellent
Right to Deny Services
Should be Empty:

Applicant Requirements

Transitional Housing Program

Please rate your ability to handle the following skills: