C o v e n a n t H o u s e A l a s k a T r a n s i t i o n a l L i v i n g P r o g r a m

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1 Application Which Program are you applying for? Rights of Passage Passage House Today s Date General Information Name Current Phone Number Current Address(street and number, city, state and zip) Date of Birth / / Age Sex: Male Female Birthplace(City and State) What was your most recent living situation? Covenant House Mental Health Facility Friends/ Relatives Street Drug Treatment Rental Housing Emergency Shelter Medical Hospital Other (specify) Transitional Housing Jail/Prison/Detention Emergency Contact Name Relationship Phone (home) Phone (work) Street Address(street and number, city, state, and zip code): Ethnicity (Check all that apply) African-American Asian/ Pacific Islander Native American specify tribe Alaskan Native Corporation Caucasian Hispanic Other (specify)

2 Identification Social Security Card Birth Certificate Drivers License/State ID Card School ID Card Military Dependent ID Card Medical Insurance Card Employment Authorization Document Number Income Issuing Authority What is your monthly income (total before taxes): $0 $501-$1000 $2001+ $1-$ $1001-$1500 $251-$500 $1501-$2000 Are you currently employed? Yes No If yes, what is the name of the company you work for? Supervisor s name : Work address Work Phone Current wage $ / hourly Hours per week Current source(s) of income (check all that apply): SSI Employment Income Food Stamps Social Security Child Support Medicare Public Assistance Unemployment income None SSDI AFDC Medicaid Veteran s Benefit Native Corporation Other (specify) Assistance from family 2

3 Education Do you have your high school diploma? Yes If yes, date of graduation: / / no What was the last grade you attended? What school did you last attend? Please explain why you left: Do you have your GED? Yes no If yes, date of completion: / / Legal History Have you ever been charged with a crime(s)? Yes No If yes, please specify: Have you ever been convicted of a crime(s)? Yes No If yes, please specify: Are you currently on probation or parole? Yes No Name of probation/parole officer: phone: Name of Public Defender/ attorney: phone: Do you have any outstanding warrants? Yes No If yes, please specify: Do you have any court dates pending? Yes No If yes, please explain: Date: Medical History Have you ever been hospitalized? Yes No If yes, please explain: Do you have any current physical health problems? Yes No If yes, please explain: 3

4 Are you currently taking any medication for a physical condition? Yes No Name of medication(s): Do you have any allergies? Yes No If yes, please describe: Do you have any other special needs we should be aware of? Yes No If yes, please explain: Are you currently pregnant? Yes No If yes, what is your expected due date: Doctor s Name Phone Number Mental Health History Have you ever received inpatient mental health services? Yes No If yes, please explain the circumstances: Location: Date: Have you ever been in counseling? Yes No If yes, please explain the circumstances: Location: Date: Are you currently taking any medication(s) for mental health reasons? Yes No Name of medication(s): Substance Use History Have you ever received inpatient treatment for drug or alcohol abuse? Yes No Location: Date: Have you ever been in counseling for drug or alcohol abuse? Yes No Location: Date: 4

5 Family Information Mother/Guardian Name: Living Deceased Never Known Father/Guardian Name: Living Deceased Never Known Do you have any brothers or sisters? Yes No If yes, how many? brothers sisters What is your current marital status? Do you have any children? Yes Never married Divorced Separated No If yes, Names Age(s) With whom are they living? Thank you for your interest in the Covenant House Transitional Living Program. Please return this application to: Rights of Passage Passage House Attn: Program Coordinator Attn: Program Coordinator 750 W 5 th Avenue P.O. Box Anchorage, Alaska Anchorage, AK (907) Fax# (907) (907) Fax#

6 Application Guidelines Because TLP serves youth who are working toward greater independence and responsibility, the application process is designed to move youth in that direction. This six-step process helps determine the youth's commitment, motivation and need for the program. This process is described below: 1. Self-Referral/Case Manager Referral-Referral form must be completed by the applicant and submitted to the TLP Program Coordinator. 2. Application Form -- The applicant should complete all sections neatly and in ink. If a section does not apply to the applicant, mark it N/A. 3. Autobiography -- The autobiography should be an honest overview of the applicant's life. It should be typed or written neatly in ink. The following topics may be used as a guideline for applicant writing the autobiography: Personal Information. Full name, birthday, present age, and ancestry. Applicant describes his or her personality, strengths and weaknesses. Parents. Names, ages. Where are parents now? Applicant describes personal relationship with parents as applicant grew up. Describes parents discipline methods. How did applicant feel about discipline methods? Overall, how was applicant raised? How would applicant raise his or her children (same/differently)? Applicant describes his or her relationship with his or her parents today. Brothers/Sisters. Names, ages. Where are siblings now? Applicant describes his or her relationship with siblings as applicant grew up. Applicant describes his or her relationship with siblings today. Home Life. Applicant describes his or her family activities. How did applicant feel about them? Applicant describes why he or she no longer lives at home. Other meaningful people in your life. Applicant describes other people who may have had a special impact on his or her life growing up. Why? Where are they today? Interpersonal Relationships. Applicant describes his or her current group of friends. How often does applicant see them? What types of things does applicant and friends do together? Lifestyle and Activities. Applicant describes his or her interests and hobbies. How does applicant spend his or her time? School Experience. Where did applicant go to school? When? What was last grade applicant completed? Did applicant like school? What grades did applicant earn? Did applicant attend regularly? Work Experience. Applicant describes his or her responsibilities. Why applicant liked or did not like his or her jobs. Applicant describes reasons he or she left. Applicant lists his or her current employer and length of time employed. Does applicant want to continue working at current job or look elsewhere? What does applicant want to do in long term? 6

7 Medical History/Mental Health History. Applicant lists serious injuries, illnesses or hospitalizations he or she has had. Has applicant had counseling or psychiatric treatment? If so, applicant describes type of treatment and reason for treatment. Legal History. Is applicant a U.S. citizen? If not, does applicant have resident alien card? Has applicant ever been charged with crime? What was result? How old was the applicant? Drug/Alcohol History. Has applicant tried drugs/alcohol? How old was applicant when he or she first tried drugs/alcohol? What types of drugs has applicant used? How often does applicant use drugs? How often does applicant use alcohol? How did applicant get started? With whom did applicant use? Significant Events in Your Life. Applicant describes other major life events that may not have been covered in this outline: birth of siblings, loss of friend/relative, etc. Purpose for Applying for TLP. Applicant briefly describes what brought him or her to apply for TLP. What are applicant s goals? How applicants thinks TLP can help him or her achieve his or her goals. Also applicant includes areas of his or her life that he or she believes need special help or support. 4. Work History Applicant lists former employers, dates of employment, duties and names of supervisors. Applicant may submit a résumé if you have one. 5. Two Interviews Once all of the above paperwork is submitted, applicant will be scheduled for two interviews. During those interviews, applicant will be asked to discuss in depth his or her background and future goals. It is also an opportunity to ask questions about TLP. Successful completion of the interviews will result in acceptance into TLP. An intake will be scheduled as space allows. Additional Admission Criteria Age 18 through 20. Have or be willing to work toward a high school diploma or GED. Ability and willingness to be employed (full-time if not in school, part-time if attending school). Willingness to live in a community setting for up to 12 months. Willingness to participate in life skills groups in and outside of TLP. Willingness and ability to follow program structure. 7

8 Application by Referring Case Manager Covenant House Another Referring Agency (Specify) Case Manager Date Youth Briefly state why you are referring this youth to a transitional living program. Why is TLP preferable over other options? List the youth s strengths as you see them. List areas in which you feel the youth needs improvement. Comment on the youth s occupational and educational performance. Do you feel this youth displays adequate skills necessary to live in a TLP? (ie: judgment, reliability, coping skills, level of trust, peer interaction.) 8

9 Additional comments: Case Manager Signature Date Coordinator Signature Date Distribution: Youth s File ROP Staff Program Director 9