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Application Form
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» Application Form
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YOUTH INFORMATION
Name
*
Social Security #
Current Address
Apart #
City
State
Zip
Emergency Contact
*
Phone #
*
Email
*
Social Media: Check √ all that apply
YouTube
Twitter
Instagram
LinkedIn
Facebook
Snapchat
Please List Usernames
Date of Birth
Age
Gender
Ethnicity
US Citizen?
Primary Language
If you are female: Are you pregnant?
If you are a male: do you have a baby on the way?
Do you have any children?
If so, how many?
Ages of Childrens?
Are your children living with you?
SCHOOL INFORMATION
School or Program name
Grade
Do you want to go to College?
Yes
No
If so, where?
What would you like to study?
If you are not in school:
Last grade completed
School Name
Why did you stop attending school?
Do you plan on going back to school?
If so, where?
What is your plan for returning to school?
Please list 3 steps that will help you achieve this goal:
Step-1
Step-2
Step-3
Employement Information
Where do you work?
How long?
List 3 Previous Employer(s):
A. Employee Name
Start Date
End Date
B. Employee Name
Start Date
End Date
C. Employee Name
Start Date
End Date
If you are not working where have you been looking for a job?
What do you want to do as a career?
Legal History
Have you ever been arrested?
What have you learned from that experience?
JUST A LITTLE MORE…
. Please describe how you would handle a conflict with a roommate?
Why do you want to be in supportive housing?
List what you believe we can help you accomplish in supportive housing?
Would you be willing to meet with a therapist monthly?
Are you willing to take random drug tests for the first 30-days?
IF NOT, then would you be willing to participate in drug use sessions with a therapist?
Please let us know any debt you have (examples: old cell phones, past landlord rental debt)
TO BE FILLED OUT BY REFERRAL (Advocate, Case Mgr., Guardian)
Referral Source (organization/person)
Phone #
Case Manager
Phone #
Email
Reason for referral
Current living situation
Former foster youth
How long in foster care?
Income Source
Employed
Pess
AfterCare
EXTENDED FOSTER CARE
SOCIAL SECURITY
Others
Involvement In:
Fire Setting
Date
Notes
Violent/Assault
Date
Notes
Property Destruction
Date
Notes
Gang Affiliation
Date
Notes
Sexual Offense
Date
Notes
Charges Pending
Date
Notes
Substance Use
Date
Notes
Suicide Thoughts
Date
Notes
Suicide Attempts
Date
Notes
Baker Act
Date
Notes
CASE MANAGER/THERAPIST SECTION
Is there a current diagnosis:
Axis 1
Axis 2
Axis 3
Axis 4
Axis V (GAF)
Current Medication
A. Current Medication
Dosage
Reason
B. Current Medication
Dosage
Reason
C. Current Medication
Dosage
Reason
Past Medication
A. Past Medication
Dosage
Reason
B. Past Medication
Dosage
Reason
C. Past Medication
Dosage
Reason
Medical Issues / Allergies
Current Therapist
Phone #
Agency Name:
Person Completing Form
Phone #
Signature
Date
AUTHORIZATION TO RELEASE INFORMATION
Program Applicant Name
DOB
Information to be released by or exchanged with the following:
Referral source such as case manager, foster parent, GAL, mentor, program staff, etc. The Open Door House
Others
The following information may be released and exchanged:
History and Physical Exam
Educational -Tests & Reports
Court/Agency Documents
Chemical Recovery History
Family System Evaluation
Therapist Orders
Nursing Notes
School Attendance
Discharge Summary
Dates of Hospitalization
Mental Status
Diagnoses
Consultation Reports
Psychosocial Report
Psychiatric Evaluation
Crisis Intervention Reports
Treatment Plans
Medical Records
School Records
Lab Results
Psychological Evaluation
Treatment Team reports
Progress Notes
Verbal Exchange Other (specify)
APPLICANT NAME
SIGNATURE
Date:
Submit
