Self-Referral & Housing Application Form
*PLEASE NOTE: Our organization is a nonprofit currently in the process of obtaining licensure. At this time, we are not operating as a homeless shelter, and our Transitional Living Program is unable to provide residential services to individuals under the age of 18. Currently, we are able to offer support to young adults between the ages of 18 and 20. Participation in our program is not guaranteed and is determined through an application, interview, and screening process*
About You
Full name
*
First Name
Last Name
Preferred name (if different)
Preferred Pronouns
Gender at Birth
*
Male
Female
Date of Birth
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Current Situation
Where are you staying right now?
*
With family or friends
Couch surfing
Shelter
Other
Why You’re Applying
In your own words, what’s going on and why do you need housing?
*
Recent Housing History
Where have you stayed in the past 12 months?
*
Please select any of these that were once or currently are applicable
Foster Care
Therapeutic Foster Care or Easter Seals
Group Home
Adopted before 17
Adopted after 17
PRTF (Psychiatric Residential Treatment Facility)
Short Stay at Mental Hospital or Mental Health Facility
Homelessness
Juvenile Justice
Safety Check
Are you currently safe where you are?
*
Yes
No
Have you had any of these safety concerns recently?
*
Thoughts of harming yourself
Someone hurting you
Thoughts of harming someone else or an animal
Unsafe living situation
None
If you checked any safety concerns, please briefly explain.
Daily Life
Are you currently in school?
*
Yes
No
Please share highest education level completed and name of school you last attended
Do you have a job right now?
*
Yes
No
Name of Current or Most Recent Employer if not employeed
What kind of support do you need right now? (Select all that apply)
*
Housing
Job help
School help
Life skills
Establishing Medical or Mental Health Care
Other
Health
Do you use any substances? Substances are defined as Nicotine, Vaping, Alcohol, Medications not Prescribed to You, Delta or TCH products, Heroine, Cocaine, Crack, Meth, Fentayl. Please elaborate if yes. Also, explain if you do not think you will pass a drug test (which is required).
*
Do you have any basic medical or mental health needs you want us to know about? Please provide any prior diagnoses. Be honest and detailed as honest, as part of the application process will be to obtain medical or mental health records.
*
Are you taking any medications right now?
*
Yes
No
If yes, please provide name of medication and reason for taking.
*
Support System
Is anyone helping you right now?
*
Yes
No
If yes, who is helping you?
Consent
I understand this is an application and not a guarantee of placement.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
Should be Empty: