KRISTA TRANSITIONAL HOUSING APPLICATION
NAME:_______________________________________________DATE:_____________
LAST
FIRST
MI
ADDRESS:______________________________________________________________
STREET
CITY
BIRTHDATE:__________________
STATE
ZIP CODE
HOME PHONE:_____________________
MONTH/DAY/YEAR
SEX [ ] [ ]
SOCIAL SECURITY #:________________________________
MALE FEMALE
FOSTER PARENT OR PLACEMENT NAME:____________________________________
HOW LONG HAVE YOU BEEN AT YOUR CURRENT PLACEMENT? ________________
YEARS
MONTHS
LIST PREVIOUS PLACEMENT(S): ___________________________________________
_______________________________________________________________________
PROBATION OFFICER:
SOCIAL WORKER:
____________________________
____________________________
NAME
NAME
____________________________
____________________________
PHONE
PHONE
IF SELECTED, WHEN WOULD YOU BE AVAILABLE TO MOVE IN?_________________
WHO IS YOUR I.L.S. WORKER?_____________________________________________
NAME
PHONE #
EDUCATION
GRADE LEVEL:________________
NUMBER OF UNITS COMPLETED:___________
WHEN DO YOU GRADUATE?_______________________________________________
-1-
SCHOOL CURRENTLY ATTENDING?
_________________________________
NAME
_________________________________
ADDRESS
_________________________________
_________________________________
PHONE #
_________________________________
CONTACT PERSON
IF NECESSARY, ARE YOU WILLING TO CHANGE HIGH SCHOOLS TO BE PART OF
THIS PROGRAM?____________ IF NO, PLEASE EXPLAIN:______________________
_______________________________________________________________________
WHAT ARE YOUR FUTURE EDUCATION/VOCATIONAL GOALS?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
EMPLOYMENT
Please list most current information first.
________
________
_________________________
FROM
TO
EMPLOYER NAME
_________________
POSITION
_________________________
ADDRESS
_________________
PHONE#
_________________________
_________________
SUPERVISOR
________
________
_________________________
FROM
TO
EMPLOYER NAME
_________________
POSITION
_________________________
ADDRESS
_________________
PHONE#
_________________________
_________________
SUPERVISOR
WHAT ARE YOUR JOB/CAREER GOALS?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
-2-
MEDICAL
When was your last C.H.D.P. exam?______________________________
Dental exam?______________________________
Vision exam?______________________________
List any medical condition you have including dental and visual. ______________________
_________________________________________________________________________
(Females) Are you using any form of birth control?
______________________________________
Are you taking medication? If so, list what you take and how often.
_________________________________________________________________________
_________________________________________________________________________
Tell me about your mental health history.______________________________________
_______________________________________________________________________
List your drug and alcohol use and age used.
___________________
________
__________________
AGE
___________________
________
________________ __
AGE
___________________
________
___________
AGE
___________
AGE
________________ __
AGE
___________
AGE
Are you currently or have you been in a drug/alcohol counseling program? If so, where,
when, and with whom? ______________________________________________________
_________________________________________________________________________
Physicians Name:________________________________ Phone#:__________________
Dentists name:__________________________________ Phone#:__________________
Optometrists Name:______________________________ Phone#:__________________
Mental health providers name:______________________ Phone#:_________________
Therapist or counselors name:______________________ Phone#:_________________
-3-
LEGAL
Have you ever been arrested?
Yes____
No____
What were you arrested for and how old were you?________________________________
_________________________________________________________________________
_________________________________________________________________________
What else would you like us to know about you? __________________________________
_________________________________________________________________________
_________________________________________________________________________
Convince us why we should accept you for this program. Tell us your strengths and how
they will help you succeed in T.H.P.P.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
*We will not discriminate based on race, gender, sexual orientation, or disability.
The above information is true. I understand that if I purposefully leave out information, I
may be turned down for this program.
__________________________________________
_____________________
SIGNED
DATE
-4-
