Holly Place THP

21573 Foothill Blvd., #210, Hayward, CA 94541

Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

PERSONAL INFORMATION
To be considered for our Transitional Housing Program, you must complete this application in its
entirety. Answer all question(s) or indicate N/A if not applicable.

(Please Print Legibly)

Today’s Date:
Name:
Current Address:
City: State: Zip Code:
Best Contact Telephone #: ( )
Email: Date of Birth: Age:
Gender:
Pronoun: Orientation:
Social Security Number:--------------- Referral Resource:

Ethnic Identity: Circle the proper code for your ethnic group, circle all that apply (OPTIONAL)
Code(s):
1.American Indian or Alaskan Native 6. Cuban 12. Laotian
2. Black, non-Hispanic, including African 7. Puerto Rican 13.Vietnamese
3. Mexican American, Mexican, Chicano 8. Other Latino 14. Filipino
4. Central American 9. Chinese 15. White
5. South American 10. Japanese 16. Pacific Islander
11. Korean

Do you have children? Yes or No. If yes, how old? Do you have custody?

Currently on Probation: ___Yes ___No Ever Been on Probation: ___Yes ___No

Name of current Social Worker: County:

Email: Phone:

Name of current/last Probation Officer: County:

Email: Phone:

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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

EMERGENCY CONTACT INFORMATION

Name: Relationship:

Address:

City: State: Zip Code:

Best Contact Telephone #: ( )

EDUCATION
Have you received any of the following? If yes, which one?
___GED ___High School Diploma ___Certificate of Completion
If not enrolled in school, are you interested in enrolling in school? __Yes___No

What best describes your current education status?

___Enrolled in a GED program-Name of school?
___Enrolled in High School-Name of school?
___Enrolled in Adult Education Program-Name of school?
___Enrolled in Community College-Name of school?
___Enrolled in a 4-year university-Name of school?

Do you currently have an IEP? ___Yes ___No

Have you ever had an IEP? ___Yes ___No

EMPLOYMENT
What best describes your employment status?
_____Employed Part-time
_____Employed Full-time
_____Not currently employed
If employed, name of current Employer:
Job Title:
Address & City:
Employer Business Number: ( )
If not employed, what is your primary source of income?
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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

REFERRAL/AGENCY SOURCE

Name of person who referred you to our program:

Relationship: Agency (if any):

Best Contact Telephone #: ( )

Email:

WELLNESS

Which of the following describes your general emotional state? (Check All That Apply)

___Stable ___Unstable ___A little depressed ___Very depressed ___None of them

History of any of the following? (Check All that Apply)

___Suicidal thoughts/intentions ___Suicide attempts
___Uncontrollable fits of rage ___Homicidal thoughts/intentions

Have you ever had a mental health diagnosis? ___Yes ___No ___Unknown

If yes, please specify:

Do you currently have a therapist? ___Yes ___No

If yes, Name: Phone:( )
We will not contact your therapist without your permission

Do you have a psychiatrist? ___Yes ___No

If yes, Name: Phone:( )
We will not contact your therapist without your permission

Do you receive SSI/SSDI: ___Yes ___No

If yes, what do you receive SSI/SSDI for?

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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

Please list any medical conditions past or present:

Please list any mental health issues past or present:

Please list all prescription medication that you are currently taking:

Have you ever been hospitalized?

If yes, please explain:

Do you drink alcohol? ___Yes ___No If yes, how often?

Do you currently use drugs? ___Yes ___No

If yes, which drugs?
How often?

Do you smoke cigarettes? ___Yes ___No If yes, how many per day?

Do you smoke marijuana? ___Yes ___No If yes, how much per day?

Have you ever been in a treatment program for substance abuse? ___Yes ___No
If yes, name of the program:
Dates of treatment
My family network is: ___Very Supportive ___Supportive ___Not Supportive ___No Contact
My social network is: ___Very Supportive ___Supportive ___Not Supportive ___No Contact

Have you ever been arrested? ___Yes ___No

If yes, for what?

What was the result?

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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

LOCATION AND HOUSING

What neighborhood/city best describes the location of the following people or things?
Your Job:
Your Kinship/Family network:
Your Social Network:
What city/cities are you interested in living?

What best describes your current living situation?

___Emergency shelter
___Homeless or other unstable housing (street, car, etc.)
___Institutionalized (just exited hospital, jail, mental health facility with no place to go):
Specify:
___Living with relative or other person in stable housing (rent free)
___Renting
___Shared housing (paying rent)
___THP program - Specify:
___Unstable housing situation (couch surfing with relatives, friends, or other people)
Do you feel you have safe and stable housing? ___Yes ___No
If no, do you need emergency shelter? ___Yes ___No

Do you require reasonable housing accommodation due to a disability? ___Yes ___No

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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

LIFE SKILLS

Do you know how to cook? ___Yes ___No

Do you know how to clean? ___Yes ___No

Have you ever had a roommate? ___Yes ___No

Was the experience positive or negative? (Explain):

Do you have experience with making and keeping a monthly budget? ___Yes ___No

Are you able to pay bills on time? ___Yes ___No

Do you own a credit card? ___Yes ___No

Do you have a bank account? ___Yes ___No If yes, what type? ___Checking ___Savings

Do you owe money on school loans? ___Yes ___No

Do you know how to use public transportation? ___Yes ___No

Do you own a car? ___Yes ___No

Do you have any pet(s)? ___Yes ___No If yes, how many?

Type of pet(s) you have?

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 Holly Place THP
21573 Foothill Blvd., #210, Hayward, CA 94541
Office: 510.733.6800 Fax: 510.733.6801 Email: info@hollysplace.org
Application

PERSONAL GOALS

Please briefly state your short term and long-term goals and describe how getting into a
Transitional Housing program will help meet your short- or long-term goals?

Applicant’s Signature:

Date:

All information will be kept confidential and used only in determining your eligibility for the program. Remember,
you must complete all sections and parts of the application to receive an interview. Holly’s Place will also work
closely with the county staff who is assigned to you for all other required and needed documents.

*By signing above, you consent to release your court report.

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