Transitional Housing UNIVERSAL APPLICATION Please enable JavaScript in your browser to complete this form. YOUTH INFORMATION Name *Social Security #Current AddressApart #CityStateZipEmergency Contact *Phone # *Email *Social Media: Check √ all that applyYouTubeTwitterInstagramLinkedInFacebookSnapchatPlease List UsernamesDate of BirthAgeGenderEthnicityUS Citizen?Primary LanguageIf 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 nameGradeDo you want to go to College?YesNoIf so, where?What would you like to study?If you are not in school:Last grade completedSchool NameWhy 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-1Step-2Step-3 Employement Information Where do you work?How long?List 3 Previous Employer(s):A. Employee NameStart DateEnd DateB. Employee Name Start Date End DateC. Employee NameStart DateEnd DateIf 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 ManagerPhone #EmailReason for referralCurrent living situationFormer foster youthHow long in foster care?Income SourceEmployedPessAfterCareEXTENDED FOSTER CARESOCIAL SECURITYOthersInvolvement In:Fire SettingDate NotesViolent/AssaultDate NotesProperty DestructionDate Notes Gang AffiliationDate Notes Sexual OffenseDate Notes Charges PendingDate Notes Substance UseDate Notes Suicide ThoughtsDate Notes Suicide AttemptsDateNotes Baker ActDate Notes CASE MANAGER/THERAPIST SECTION Is there a current diagnosis: Axis 1Axis 2Axis 3Axis 4Axis V (GAF)Current MedicationA. Current MedicationDosage ReasonB. Current MedicationDosageReasonC. Current MedicationDosageReasonPast MedicationA. Past MedicationDosageReason B. Past MedicationDosageReasonC. Past MedicationDosageReasonMedical Issues / AllergiesCurrent TherapistPhone #Agency Name: Person Completing FormPhone #SignatureDate AUTHORIZATION TO RELEASE INFORMATION Program Applicant NameDOB 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 OthersThe following information may be released and exchanged:History and Physical ExamEducational -Tests & ReportsCourt/Agency DocumentsChemical Recovery HistoryFamily System EvaluationTherapist OrdersNursing NotesSchool AttendanceDischarge SummaryDates of HospitalizationMental StatusDiagnosesConsultation ReportsPsychosocial ReportPsychiatric EvaluationCrisis Intervention ReportsTreatment PlansMedical RecordsSchool RecordsLab ResultsPsychological EvaluationTreatment Team reportsProgress NotesVerbal Exchange Other (specify)APPLICANT NAMESIGNATUREDate:Submit
