Youth Application. Hillcrest Transitional Housing YOUTH PROGRAM APPLICATION Step 1 of 19 5% GENERAL INFORMATION Applicant Name:* Please enter your first and last name: First Last SS# (last four digits)* Date of Birth* Age: Please enter a value between 1 and 100. Gender* Select GenderMaleFemaleOther Marital Status Select StatusSingleMarriedDomestic PartnerDivorcedSeparatedWidowed CURRENT LIVING ARRANGEMENT Where are you living right now? (select one): Select Living LocationHouse / Apt.FriendsRelativesShelterHotelStreetCarOther If other, specify where you live.* Phone* Other Phone Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How long have you been staying there? How many people live there? Please enter a value between 1 and 100. Where do you sleep? Select Sleeping LocationCouchBedFloorOther PROGRAM INFORMATION Have you ever applied to this program before? Yes No If Yes, When? If Yes, What happened? How did you hear about Hillcrest? Do you know anyone who has been in THIS program? Yes No If Yes, Who? What are your reasons for applying to Hillcrest? Please explain circumstances: Have you ever been in any other independent living program? Yes No If Yes, When? If Yes, Where? Why did you leave that program?: If you are accepted into this program and you are not from this area (Kansas City MO/KS), describe how comfortable you will feel working on goals for work and school for the duration of the program (18 months) in an area you are unfamiliar?: List three things you like about yourself: List three things about yourself that you feel need improvement/attention: EDUCATION Select Level of Education Completed: Select EducationSome High SchoolGEDTrade/Skill SchoolIEP or Special Ed classesSome CollegeOther If Some High School, what was the last grade completed? Select Highest High School Grade Completed9th Grade10th Grade11th Grade If Some College, What was your area of study: If Other, Please explain: Please enter all schools you attended: (click the plus sign to add another school) Level (High School, GED, College, Trade, etc.) Name of School(s) Years Attended/Graduated Please describe any problems you have had in school: FAMILY INFORMATION Please list your family members (click the plus sign to add another family member) Parent Name Address (city, state) Phone Please list your Brothers and Sisters (click the plus sign to add another sibling) Brother/Sister Name Age Phone CHILDREN Do you have children? Yes No Please list your children: (click the plus sign to add another child) Name Age Gender (M or F) Is the other parent(s) involved in your child's life? Yes No If you have children, please list your children's other parents (click the plus sign to add another parent) Name of Other Parent Child Name Please describe how the other parent(s) are involved in your child's life: List all who would be living with you in the apartment (please include yourself on the first line): (click the plus sign to add another person) Name Relationship Date of Birth Age Type of Custody EMERGENCY CONTACTS List emergency contact names and phone numbers. If you have a child, list the child's other parent and /or a relative of the child as an emergency contact: (click the plus sign to add another contact) Name Phone Relationship To get a sense of what you have been through, please answer the following questions honestly: HEALTH INFORMATION Are you pregnant? Yes No Term of Pregnancy If yes, how far along are you? Prenatal Care Are you getting prenatal care? Yes No If Yes, Where are you receiving prenatal care? Health concerns / problems: Medications: Name of Physician: Do you have any allergies? Yes No If yes, what are your allergies? Are you concerned about sexually transmitted diseases? Yes No If Yes, What are your concerns? SUBSTANCE USE Do you smoke cigarettes? Yes No If Yes, How many per day How long have you smoked? When was the last time you used drugs and/or alcohol? What drug/alcohol do you use most often? How frequently? LEGAL Have you ever been arrested? (DWI, bad checks, assault, etc.) Yes No If Yes, why were you arrested? Have you ever served time in jail? Yes No If Yes, How long? If Yes, Why? Do you have pending tickets (speeding, parking, etc.)? Yes No If Yes, What for? Do you have any warrants? Yes No If Yes, What for? Are you currently on parole, probation, or diversion? Yes No If Yes, How many months/years left? Parole/Probation Officer: Parole/Probation Officer Phone Number: COUNSELING Have you ever been in counseling? Yes No Therapist: Program Name: What problems are you working on ? Have you ever been in a mental health hospital? Yes No If Yes, When were you in a mental health hospital? What is the name of the mental health hospital? Why were you in the mental hospital? What problems are you working on? What medications you have tried? Have you ever been in a drug or alcohol program? Yes No If Yes, When? If Yes, Where? Are you an AA participant? Yes No Are you an NA participant? Yes No SOCIAL SKILLS On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself at the following: Hygiene: Select rate1-Poor2345-Best Household Chores: Select rate1-Poor2345-Best Wake up on your own: Select rate1-Poor2345-Best Laundry: Select rate1-Poor2345-Best Being on time: Select rate1-Poor2345-Best Getting along with others: Select rate1-Poor2345-Best INDEPENDENT LIVING SKILLS On a scale of 1-5 (1=Poor, 5=Best), how would you rate your ability to: Purchase Food: Select rate1-Poor2345-Best Budget Money: Select rate1-Poor2345-Best Prepare well balanced meals: Select rate1-Poor2345-Best Purchase clothing: Select rate1-Poor2345-Best Take care of others: Select rate1-Poor2345-Best Use banks: Select rate1-Poor2345-Best Find jobs: Select rate1-Poor2345-Best Hold jobs: Select rate1-Poor2345-Best Use public transportation: Select rate1-Poor2345-Best Use Hospital: Select rate1-Poor2345-Best Use Library: Select rate1-Poor2345-Best Knowledge of Colleges: Select rate1-Poor2345-Best Use Computer: Select rate1-Poor2345-Best Use Telephone: Select rate1-Poor2345-Best PROBLEM SOLVING How do you deal with your anger?: How do you deal with peer pressure?: How do you deal with authority figures?: What do you do with your free time?: What do you do when you are alone?: What are your hobbies?: WORK AND INCOME Job History Information (Last 3 Years): (click the plus sign to add another job) Dates Company Name Pay Rate Duties Reason for Leaving Income currently received from Job, Food Stamps, TANF, DFS, SSI, etc.: If child support is owed to you, please list monthly/total amount owed. (click the plus sign to add another income source) Source Amount (weekly / monthly) Current Case Worker Name? Case Worker Phone Number Name of Social Services Office (DFS, SRS, City and State): TRANSPORTATION Do you have a driver's license? Yes No Do you have a car? Yes No Make: Model: Color: Plate #: Insurance Company Name: Would you be willing to use the Metro Bus? Yes No PERSONAL OBJECTIVES Why do you feel you would benefit from participating in Hillcrest's program?: References By listing names and phone numbers below, you are indicating that you agree to allow us to contact anyone listed as a reference to aid in our decision to accept you into the program. Please do not list family members or friends. List persons from other programs you have been in, counselors, school personnel, employers, etc. (click the plus sign to add another reference) Name Phone SOCIAL HISTORY REQUEST This task is part of the Transitional Living program (TLP) application process. The purpose of this document is for you to tell the intake staff about yourself. This document is used to help the intake team make a decision about whether you are appropriate for the program. This document should be neatly written or typed. You are encouraged to give as much detail and explanation in your social history as possible. Below is a description of things that should be included in your social history, you may include any additional information. Introduction: Describe how the last six months have been for you. Why are you currently interested in Hillcrest as a place to live? General Information: Where were you born? Where have you lived and with whom have you lived? How long have you lived in each place? Have you had any out of home placements or psychiatric hospitalizations? Are you currently being seen by a therapist or psychiatrist? Do you have any diagnosis? School: What schools have you gone to? How have your school years been so far? have you had any suspensions or expulsions? What school are you currently enrolled? If you are not enrolled anywhere, are you willing to return to school for either your GED or diploma? Have you ever been in a learning disorder or behavioral class? Relationships: Describe your family and friends. Who do you get along with and why? Who do you not get along with and why? Name or describe particular people you feel you can trust and go to for support. What are your strengths as a friend? Legal Issues: Have you had any trouble with the law? Do you have any outstanding tickets or warrants? Do you have any pending court cases? Free Time: Do you use drugs or alcohol? If you do use, do you feel like it is a problem for you? Do you smoke cigarettes? What hobbies do you enjoy or what hobby would you like to learn about? Goals: What are your plans for the future? If you have any questions or are unable to complete the social history, please call the Case Manager at (913) 827-8462. Documents (Please provide copies of the following when the Case Manager contacts you to set up an inerview for housing) 1. Proof of age (one of the following): Birth Certificate, School ID, Driver's License 2. Social Security card 3. Release of Information forms for: Last school attended, current / former therapist, Probation Officer, past independent living programs, psychiatric hospital(s), psychiatrist. 4. If you own a car, you will need to provide: Driver's License, current insurance card By submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge, I agree to allow my references to be checked and I agree to the application process. Programs Rules The following rules of conduct shall be in effect while Clients participate in the Hillcrest Transitional Housing program. Violation of any rule will, at the sole discretion of the Board or Staff, be cause for immediate dismissal from the program, causing forfeiture of shelter space & supportive services. No illegal activity of any kind will be permitted Use or possession of alcohol, firearms or illegal drugs is prohibited. Curfew is 11:00 pm. This can only be waived for work schedules. Your Guests must be out of the shelter buildings by 10:00 pm. Quiet hours are: 10:00 pm through 7:00 am. No overnight guests are allowed unless permission is obtained through a staff member. Children under the age of 13 must be attended by an approved adult at all times. Children must be enrolled in the school district nearest Hillcrest or in the district your family originates from. They must attend school everyday required.. No fighting of any kind will be tolerated. No pets of any kind will be allowed. Smoking is NOT permitted inside the shelter units, buildings, or offices. Clients must keep shelter units & common areas clean and neat. All adults in the Hillcrest program are expected to work at least 40 hours per week. All adults must attend scheduled meetings & appointments. A $100 program deposit will be taken at time of shelter entry, or at time of first paycheck. I acknowledge that Hillcrest staff may enter my shelter unit to do maintenance or cleaning checks when I am not present without notification beyond immediate announcement. I acknowledge the Hillcrest staff will also perform scheduled checks of my shelter unit. I acknowledge that Hillcrest staff may require me to submit to random drug testing while I am participating in the transitional housing program, and that my refusal to do so could result in being asked to immediately vacate the program. I have read and understand that if I violate any one of these rules I may be dismissed from the Hillcrest program. I agree to hold Hillcrest Transitional Housing and/or any other parties associated with this program in any way whatsoever, singly, or collectively, from any blame or liability for injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in this program or in activities associated therewith. I give permission for information to be released about me and my children, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency, including Mid America Assistance Coalition & Rosie HMIS databases, or any other person deemed necessary by Hillcrest Transitional Housing. I agree that my acceptance into the Hillcrest Transitional Housing Program is not a rental agreement, and that this is not a landlord/tenant agreement, but an application for temporary homeless shelter & supportive services provided by the Hillcrest program. By submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge, and I understand and agree to the Rules as put forth above.