Applicant Information Name: Date of birth: Current address: Transitional Housing Application SSN: Dr. License Number: City: State: ZIP Code: Phone: Email: Name of Last Social Worker or Probation Officer: Original Birth Certificate: Original Social Security Card: Valid Driver s License: 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 Race (circle all that apply): American Indian Alaskan Native Asian Black or African American Pacific Islander White Other Presenting Issue: Alcohol Abuse Developmental Disability Domestic Violence *must have mental health diagnosis Family Information Drug Abuse HIV/AIDS Mental Illness Physical Disability Other How many children: How many children living with you: Child Custody Order: Are you pregnant or female pregnant with your baby: (due date _) 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:
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 Current or Last Employer: Company: _ Job Title: Start Date: _ End Date: Hourly Pay: Brief Description of paid Employment Experience: Experience Brief Description of all Community Service and Volunteer Work Performed: Education Information School Status: Education Attending School o High School o Vocational School o Junior College o 4-Year College/University o Other Not Attending School Last Grade Completed: Name of last high school attended: _ Name of school currently attending: _ What is your course of study? _ When will you graduate? _ Do you have your diploma? Do you have your GED? Do you have a copy of your diploma or GED? N/A Character References (Please list three adult references) Name Address Phone Relationship
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? If, please explain : Criminal Arrest Status Have You Been Arrested? 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
Health Information Do You Have Insurance? Do You Have Your Insurance Card? Do you have any significant physical or mental health problems that affect your employability? If, Please Explain: Could you pass a drug test today? Are you willing to take a drug test to enter or remain in a Housing Program? Are you aware that you may be tested at any time during your participation in the Housing Program to remain eligible for Transitional Housing? Program Description The individuals will have access to daily therapy, daily skill building, IPR services and weekly substance abuse treatment. All individuals will be subject to random UA s, PBT s, as well as frequent, random room searches. Each individual will help design his/her own treatment plan based on individual needs. Each will also have the ability to add or amend goals as he/she makes progress through the program. Genesis Development (operating as Hope Wellness Center) and the Heart of Iowa Community Services Region have collaborated with Zion to provide substance abuse treatment on site at HWC. Zion counselors will conduct assessments and provide outpatient treatment services weekly in our facility. Meals will be provided to each individual until he/she are able to provide for him/herself. Each individual will be coached to apply for assistance programs including, but not limited to: food assistance, housing assistance, Medicaid, etc. Employment is a requirement of HWC and support will be available to assist individuals in gaining employment. Individuals graduate from the Transitional Program once they are self-sufficient in making rent payments, having a budget in place and an overall understanding of their mental health and substance abuse. Hope Wellness Staff will work with individuals to determine when goals have been completed resulting in graduation from the program. Transitional Living Resident Responsibilities: Weekly Therapy Daily Real Life Skill Building Attendance at substance abuse treatment, AA or NA Taking all prescribed medications Apply for Medicaid and assistance programs as needed Provide UA s and PBT s Comply with probation/parole requirements Comply with all HWC rules and guidelines Be open to working with all staff Progress on goals set in treatment plan Be open to processing all stressful events and triggers with staff Attend all group sessions held by staff Build a resume and apply for employment Maintain employment Pay rent in the amount of $200/month Build a weekly/monthly budget Meet with Transitional Coordinator or Peer Support Specialist weekly Work on housekeeping/cleaning skills Locate affordable housing Gain self-sufficiency in society
Essay Questions What have you heard about Hope Wellness Center? Why are you interested? What steps have you taken 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 goals in the next month? 3 months? 6 months? 1 Month) 3 Months) 6 Months)
How do you plan to achieve these goals? 1 Month) 3 Months) 6 Months) 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.)
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:
Supervisory Approval Required Beyond this Point Eligibility Determination HWC Eligible Program for Which this Individual is Available PHASE 1 PHASE 2 Additional Recommendations/Referrals Additional Information