Transitional Housing Application
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1 Transitional Housing Application Applicant Information Name: Date of birth: SSN: ID Number: Current address: City: State: ZIP Code: Phone: Name of Last Social Worker or Probation Officer:: Original Birth Certificate: Original Social Security Card: Valid Driver s License: YES NO YES NO YES NO I am or have been in: Foster Care Probation Circle all that apply Legal Guardianship None Primary Language: Demographic Information Gender: Male Marital Status: Single Divorced Hispanic or Latino: Female Separated Married YES NO Race (circle all that apply): American Indian Alaskan Native Asian Black or African American Pacific Islander White Other Special Needs: Alcohol Abuse Developmental Disability Domestic Violence Drug Abuse HIV/AIDS Mental Illness Physical Disability Other Family Information How many children: How many children living with you: Child Custody Order: YES NO Are you pregnant or female pregnant with your baby: YES (due date ) NO Financial Information Income Sources (circle all that apply): Child Support Employment Income Food Stamps General Public Assistance Medicaid/Medi-Cal No Financial Resources Section 8 Housing State Children s Health Insurance Program Social Security Social Security Disability Insurance Supplemental Social Security Income (SSI) Temporary Assistance to Needy Families (TANF) Unemployment Benefits Veterans Benefits Veterans Healthcare Other:
2 Employment Information Employment Status: I am currently employed I am not currently employed I was fired I was laid-off I quit my job I have never held a job I am currently looking for work Brief Description of paid Employment Experience: Current or Last Employer: Company: Job Title: Start Date: End Date: Hourly Pay: Experience Brief Description of all Community Service and Volunteer Work Performed: Education Information School Status: Attending School o High School o Vocational School o Junior College o 4-Year College/University o Other Not Attending School Name of last high school attended: Name of school currently attending: What is your course of study? When will you graduate? Education Do you have your diploma? YES NO Do you have your GED? YES NO Last Grade Completed: Do you have a copy of your diploma or GED? YES NO N/A Character References (Please list three adult references) Name Address Phone Relationship
3 Living Situation Homeless Shelter Domestic Violence Center Transition Age Youth Shelter Other Temporary Shelter Rental Housing On the Street Other Transitional Living Program Parent/Legal Guardian s Home Other Adult s Home Friend s Home Relative s Home Foster Home Group Home Job Corps Drug Treatment Center Military Educational Institution Mental Hospital Correction/Detention Center Other Have You Ever Been Homeless? YES NO If YES, please explain : Criminal Arrest Status Have You Been Arrested? YES NO Currently on: Probation Parole N/A I Have Been In: Juvenile Hall Jail Prison Detained I owe restitution ($ ) Please list your arrest history Date Age Charge What Happened Probation Officer Commitment Length
4 Health Information Do You Have Medicaid? YES NO Do You Have Your Medicaid Card? YES NO Do you have any significant physical or mental health problems that affect your employability? YES NO If YES, Please Explain: Could You Pass a Drug Test Today? YES NO Are You Willing to Take a Drug Test to Enter or Remain in a Housing Program? YES NO Are You Aware That You May be Tested at Any Time During Your Participation in the Housing Program to Remain Eligible for Transitional Housing? YES NO Program Application Select the Transitional Housing Program Applying For (check all that apply) Phase 1 The resident will receive daily therapy, daily skill building, IPR services and weekly substance abuse treatment. All phase 1 residents will be given random UA s, PBT s, as well as frequent, random room searches. Each individual will help design their own treatment plan. They will also have the ability to add additional goals as they progress in the program. Genesis Development (Hope Wellness Center) and the Heart of Iowa Region have collaborated with Zion to provide substance abuse treatment on site at HWC. Zion counselors will conduct assessments at intake and also provide Intensive Outpatient Treatment in our facility three days a week. Each resident will be assisted in applying for food assistance as well as Medicaid. This phase is designed to give an individual the knowledge and resources necessary to understand their mental health and substance abuse needs over a 2-3 month period. Phase 1 resident responsibilities- Daily therapy Daily real life skill building Participating in IPR Attend substance abuse treatment, AA, or NA Taking all prescribed medications Apply for Medicaid & Food Assistance Provide UA s & PBT s Comply with Probation/Parole requirements Comply with all HWC rules & guidelines Be open to working with all staff Be open to processing through all stressful events as well as triggers with staff Progress on goals set in treatment plan Attend any group sessions held by staff Once the individual starts to make progress on their plan, new privileges will be added for them; such as walking around the block without staff, walking to Casey s without staff, walking to the local grocery store without staff, or going on a day pass with family. As they approach the 2-3 month mark, the Transitional Coordinators will decide when the individual is ready to move on to phase 2. Phase 2 The resident will begin building a resume for employment. Once that is complete each resident will begin applying for 2-3 jobs per week until employed. They will also continue to maintain all therapy appointments as well as their substance abuse treatments. Each resident will be provided meals for up to two days before it becomes their own responsibility to provide food and necessities. Phase 2 is set to be a maximum three month program with discharge occurring once housing is secured. Residents graduate from Phase 2 once they are self-sufficient in making rent payments, having a budget in place and overall an understanding of their mental health and substance abuse. It is up to the discretion of the Transitional Coordinators, HWC staff and the Director of Services when an individual is set to graduate. Phase 2 resident responsibilities- Maintain weekly therapy (2-3 times if possible) Maintain weekly substance abuse treatment, AA, or NA Continuing IPR service Begin building a resume for employment Begin applying for jobs in the area they would like to live Maintain employment while on phase 2 Begin paying rent in the amount of $200 per month Build a weekly/monthly budget Provide substance free UA s as well as negative PBT s Taking all prescribed medications Meet with Transitional Coordinators once a week Work on housekeeping/house cleaning skills Comply with Probation/Parole requirements Comply with all HWC rules & guidelines Be open to working with all staff Be open to processing through all stressful events as well as triggers with staff Progress on goals set in treatment plan Attend any group sessions held by staff Locating affordable housing Gaining self-sufficiency in society
5 Essay Questions What have you heard about Hope Wellness Center? Why are you interested? What steps have you take to prepare yourself to participate in a transitional housing program? In the coming year, how will you prepare yourself for life after placement? What are your personal goals in the next 3 months? 6 months? 12 months? Goal 1) Goal 2) Goal 3)
6 How do you plan to achieve these goals? Goal 1) Goal 2) Goal 3) How do you deal with anger? Describe what happens when you get mad. How do you deal with stress? Describe what types of behaviors you have when you are stressed. How do you deal with authority figures? (ex. Teachers, law enforcement, bosses, staff, etc.)
7 How do you deal with peer pressure? How well do you get along with others? Write a 100 word essay below describing yourself I certify that the above information included on this application is true and correct. Signature Date For Hope Wellness Center Use Only Name of person receiving this application: Date:
8 Supervisory Approval Required Beyond this Point Eligibility Determination HWC Eligible YES NO Program for Which this Individual is Available PHASE 1 PHASE 2 Additional Recommendations/Referrals Additional Information
First Name Middle Name Last Name Name You Prefer Date
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