The Salvation Army of Dane County Holly House Transitional Living for Women Application Holly House is designed as an independent transitional housing program for women without children in their custody. Women may self-refer or receive a referral to Holly House through various homeless service agencies in the Dane County area. The application process includes the following parts. Please be sure to complete each section accurately and completely. Part I: Referral (preferred but not required) Part II: Application Part III: Release of Information When there is an opening, the above forms will be reviewed by the Screening Committee at Holly House. This committee is made up of The Salvation Army Social Services Director, Services Coordinator and Holly House Case Manager. The Screening Committee will: Review and process applications received for program participation. Processing applications includes: o Application review o Reference check (Please note, if an applicant has a client file at The Salvation Army, we reserve the right to reference the file.) o Credit check o Background check Interview potential program participants (if qualified). The screening/interview team may also include a current Holly House resident(s). Accept or decline applicants Please return completed applications to: The Salvation Army of Dane County Attn: Tara Barica 630 East Washington Avenue Madison, Wisconsin 53703 Fax: 608.256.0569 Page 1 of 10
Overview of Holly House Program: Holly House is designed as an independent transitional housing program for women without children in their custody who are currently homeless. Holly House is meant to empower women to make positive growth and enhance skills to transition into permanent housing within the community. The program has the ability to serve up to eight women at a time and for a period up to 24 months. Holly House is a cooperative living environment; residents are responsible for maintaining the living space and working collaboratively with house mates. Holly House is a fee-based program. Holly House program fee is $245- $305 per month depending on size of the room. Program agreements are renewed monthly. This fee includes all room, utility and case management fees. Program participants must have a regular and permanent source of income and demonstrate the ability to independently budget and manage money. Program fees must be paid by the resident; fees cannot be paid on behalf of the participant by a 3 rd party. As part of program participation, a resident may be required to obtain a payee to ensure effective money management. Holly House residents meet with a case manager on a regular basis to discuss their goals and identify appropriate objectives to achieve set goals. Residents are also expected to attend a monthly residents meeting; this meeting allows residents to meet with the case manager and other residents to discuss any strengths or concerns at Holly House. Holly House is a clean and sober living environment. Prior to entry, program participants must be clean and sober without supervision during the 12 months, at minimum, preceding application. As part of program participation, a resident may be required to participate actively and consistently in ongoing AODA treatment and/or support, as needed. Similarly, program participants with a mental health-related illness may be required to participate actively and consistently in ongoing mental health treatment and/or support, including regular use of psychiatric medications, as needed. Holly House residents are expected to be following the recommendations of other treatment providers while residing at Holly House. Any questions about this application and/or Holly House program, please direct them to: Tara Barica Services Coordinator (608) 250-2227 Tara_Barica@usc.salvationarmy.org Page 2 of 10
Part I: Referral Date: Applicant s Name: How do you know the applicant and for how long? What challenges is the applicant managing? Please include any mental health related illnesses, substance abuse history, family or social stressors. If the client is in recovery, please state the length of time clean. What are recommended service goals for the applicant? Page 3 of 10
What has been done thus far to address these goals with the applicant? What progress has been made? How is the applicant a good fit for the Holly House program? What are some of applicant s strengths? Referral Source Information Your name: Agency: Address: Phone: Fax: Thank you for taking the time to complete this referral. Signature Date Page 4 of 10
Part II: Application Please complete the application fully and completely. Incomplete applications will not be processed. It is important to provide all of the following information so that Holly House can make an informed decision regarding your qualifications. If a section does not apply, please write does not apply. Please note, additional information and/or documentation may be requested. Name: SS #: Date of Birth: Present address: Phone Number: What is the best time to contact you? Income Information Please list all sources and amounts of income. Employer name and address: Hours per week: Rate of pay per hour: Gross (before taxes) pay per month: How long have you worked here? Is this a temporary job? Yes No Employer name and address: Hours per week: Rate of pay per hour: Gross (before taxes) pay per month: How long have you worked here? Is this a temporary job? Yes No Do you receive SSI or SSDI benefits? Yes No If yes, monthly amount: Do you have a protective payee? Yes No If yes, please provide contact information below: Name Phone Address Other income received: Food Share: Yes No If yes, monthly amount: Other Source of income: Monthly amount: Page 5 of 10
Housing Information Please briefly describe your current homeless situation: Have you ever been evicted? Yes No If yes, please list the year/address/and the reason you were evicted: Please provide information about your housing history for the last 2 years, starting with the most recent. Include all places where you have lived, even if you were not on the lease or were in a residential treatment program. If you need more space, please use a separate piece of paper. 1) Date moved in: Date moved out: Address: Amount of monthly rent (your portion): Were you on a lease or the person who paid the rent for this location? Yes No If yes, please provide the following information: Landlord name and phone number: Landlord address: Do you owe money to this landlord? Yes No If yes, how much? 2) Date moved in: Date moved out: Address: Amount of monthly rent (your portion): Were you on a lease or the person who paid the rent for this location? Yes No If yes, please provide the following information: Landlord name and phone number: Landlord address: Do you owe money to this landlord? Yes No If yes, how much? Page 6 of 10
3) Date moved in: Date moved out: Address: Amount of monthly rent (your portion): Were you on a lease or the person who paid the rent for this location? Yes No If yes, please provide the following information: Landlord name and phone number: Landlord address: Do you owe money to this landlord? Yes No If yes, how much? 4) Date moved in: Date moved out: Address: Amount of monthly rent (your portion): Were you on a lease or the person who paid the rent for this location? Yes No If yes, please provide the following information: Landlord name and phone number: Landlord address: Do you owe money to this landlord? Yes No If yes, how much? Criminal History Are you currently on probation or parole? Yes No If yes, name and phone number of worker: Do you have a history of sexual-related offenses? Yes No Please list all criminal offenses other than minor traffic violations. Please include dates: Substance Abuse History Have you ever struggled with alcohol and/or drug abuse? Yes No If yes, how long have you been clean and sober? Have you ever been involved in an alcohol/drug treatment program? Yes No If yes, when and where? For how long? Did you complete program? Yes No What is the name and number of your counselor? Page 7 of 10
Mental Health History Do you have a history of mental illness? Yes No If yes, please explain: Has this been diagnosed by a doctor? Yes No If yes, are you currently seeing a psychiatrist and/or therapist on a regular basis? Yes No What is the name and phone number of your psychiatrist and/or therapist? Have you ever been hospitalized because of your mental health? Yes No If yes, when, where, and for how long? Professional References List at least 2 professional references. Please do not list a friend or relative. Name: Agency: Relationship: Length of time known: Phone: Fax: Address: Name: Agency: Relationship: Length of time known: Phone: Fax: Address: Agency Contacts Please list any other agencies or professionals you are currently working with: Name: Agency: Phone: Fax: Address: Name: Agency: Phone: Fax: Address: Name: Agency: Phone: Fax: Address: Emergency Contact Information Name: Relationship: Address: Phone: Page 8 of 10
Personal Goals / Reasons for Application Please describe your interest in the Holly House program. Include any personal goals you have and/or your reasons for applying for the Holly House program at this time. Please add any information you feel would be helpful for us when considering your application. Page 9 of 10
Part III: Release of Information I give Holly House and its representatives permission to contact all of the listed references to verify all of the information provided in the program application. I understand that, by signing below, I give Holly House the following permissions: Permission to discuss my housing history with contacts listed in the Housing Information section of this program application. This permission includes information regarding my compliance with lease terms, facility rules and/or timeliness of rental payments. Permission to discuss my mental health, alcohol and/or drug treatment history and participation with the professional contacts listed in this program application. This permission includes discussing the professional s recommended goals for applicant and any diagnostic impressions or specific diagnoses given by the professional. Permission to verify my income with the sources listed in the Income section of this program application. Permission to contact any of the agencies/professionals listed in the Agency Contacts and Professional References sections to discuss my compatibility with Holly House. Permission, if applicable, to contact my Protective Payee to discuss my ability to pay program fees. Additionally, I understand that this permission to release information can be revoked by me at any time verbally or in writing. This revocation will not pertain to any action that has already been taken regarding verification or release of information. If I do not revoke this release, it will automatically expire one year after the date it was signed. Prospective Program Participant Signature Date Page 10 of 10