Youth Program Application

Social History Request

Documents

GENERAL INFORMATION:

Applicant First Name: Applicant Last Name:

SS#: Date of Birth: // Age:
Gender: Marital Status:

Where are you living right now? (select one):
     If Other, specify:

Location:
     Phone:    Other Phone:
     Address:
     City:         State:         Zip:
     How long have you been staying there?
     How many people live there?
     How long are you allowed to live there?
     Where do you sleep?:

Have you applied to this program before? Yes   No     When?
     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?    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:

If Some High School, what was the last grade completed?
If some College, what was your area of study:
If Other, please explain:

	Names of School(s):	Years Attended/Graduated
High School/GED:
College/Trade School:
Other:

Problems you have had in school:

Family
Parents Names	Address (city, state)	Phone

Brothers/Sisters Names	Age	Phone

Your children:
Name    Age:    Gender:
     Other Parent's name:

Is the other parent ofyour child involved in your child's life?: YesNo
     If yes, how?

Name    Age:    Gender:
     Other Parent's name:

Is the other parent ofyour child involved in your child's life?: YesNo
     If yes, how?

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:
Name	Phone	Relationship

To get a sense of what you have been through, please answer the following questions honestly:

Health

(Females) Are you pregnant? YesNo
    If yes, how far along are you?
    Are you getting prenatal care? YesNo
    If yes, where?

Health concerns / problems:
Medications:
Name of Physician:
Do you have any allergies? YesNo
If yes, what?
Concerns about sexually transmitted diseases? YesNo
If Yes, what are they?:

Substance Use

Do you smoke cigarettes? YesNo          If yes, how much 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?

Social Skills

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself at the following:

Hygiene:	Household chores:	Wake up on your own:
Laundry:	Being on time:	Getting along with others:

Independent Living Skills

On a scale of 1-5 (1=Poor, 5=Best), how would you rate your ability to:

Purchase Food:	Budget money:
Prepare well balanced meals:	Purchase clothing:
Take care of others:	Use banks:
Find jobs:	Hold jobs:
Use public transportation:	Use hospital:
Use Library:	Knowledge of colleges:
Use computer:	Use telephone:

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?

Job History Information (Last 3 Years):
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.
Source	Amount (weekly / monthly)




Current Case Worker Name? Phone #:
Name of Social Services Office (DFS, SRS, City and State):

Transportation
Do you have a driver's license? YesNo
Do you have a car? YesNo
Make: Model: Color: Plate #: Insurance Co Name:
Would you be willing to use the Metro Bus? YesNo

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.
Name	Phone

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 descriiption 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 TLP 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.

List all who would be living with you in the apartment (please include yourself on the first line):

Relationship

Date of Birth

Type of Custody

(Please provide copies of the following)

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

When you have completed and submitted the entire Application for Residency, complete the social history and gather together all of the documents noted above. Email to ewinkleman@hillcrestkc.org or mail or bring documents to: Hillcrest Transitional Housing, 738 N. 31st Street, Kansas City, KS 66102. Phone #: (913) 400-2573.

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.