Housing Application

Transitional Housing Application

The purpose of this program is to support the provision of services to victims of crime between the ages of 18 and 24. Priority will be given to victims of child abuse, domestic violence, sexual assault, and victims of violent crime who were previously underserved.

Hidden
Today’s Date
MM slash DD slash YYYY
Name*
First Middle Last
Are you eligible for the Extension of Foster Care Program?
- Yes
- No
Do you plan on participating in the Extension of Foster Care Program?
- Yes
- No
Gender*
- Male
- Female
- Other
LGBTQ
- Yes
- No
Hispanic or Latino Ethnicity?
- Yes
- No
Race (select all that apply):
- American Indian
- Alaska Native
- Asian
- Black or African American
- Pacific Islander or Native Hawaiian
- Multi-Racial
- Mexican
- Mulatto
- White
- Other
Race (specify below):
Primary Language
- English
- Spanish
- Other
Primary Language (specify below)
Last Street Address
Street Address Address Line 2 City State ZIP Code
Phone
Whose Phone Number Is Listed?
- My phone
- My friend’s phone
Email
Preferred Contact Method
- E-mail
- Text
- Mail
- Phone Call
Birth Date
MM slash DD slash YYYY
Do you have your original Birth Certificate?
- Yes
- No
Social Security Number
Do you have your original Social Security Card?
- Yes
- No
Religion
How many children have you given birth to or fathered?
How many of these children are you in contact with?
If you have children, are they being cared for by a relative?
- Yes
- No
Are you pregnant or is a female pregnant with your baby?
- Yes
- No
Due Date
MM slash DD slash YYYY
Do you know how to ride Metro Transit System?
- Yes
- No
Do you have a car?
- Yes
- No
Do you have a driver’s license?
- Yes
- No
Do you have a state identification card?
- Yes
- No
Provide the identification number and State of issuance:
I am or have been in Foster Care
- Yes
- No
Name of last Case Manager:
Phone number of last Case Manager
I am or have been on probation
- Yes
- No
Name of last Probation Officer
Phone number of Probation Officer
Special Needs
Check all that apply
- Alcohol Abuse
- Developmental Disability
- Domestic Violence Victim
- Drug Abuse
- HIV/AIDS
- Mental Illness
- Physical Disability
Financial Information
Income Sources
- Employment Income
- Food Stamps
- Social Security
- Social Security Disability Insurance
- Supplemental Social Security Income (SSI)
- Temporary Assistance to Needy Families
- Unemployment Benefits
- Other
Other Income Source
Are you enrolled in Opportunity Passport at Youth Connections?
- Yes
- No
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 Name
Current or Last Employer Job Title
Current or Last Employer Start Date
MM slash DD slash YYYY
Current or Last Employer End Date
MM slash DD slash YYYY
Hourly Pay
Have you met with the Career Coach at Youth Connections?
- Yes
- No
Brief description of paid employment experience:
Brief description of all community service and volunteer work performed:
Education Information
School Status
- Attending High School
- Attending Vocational School
- Attending Junior College
- Attending 4-Year College/University
- Attending 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?
- Yes
- No
Do you have your HiSet?
- Yes
- No
Do you have a copy of your diploma or HiSet?
- Yes
- No
- N/A
What is your career goal?
Living Situation
Current Living Situation
- Correction/Detention Center
- Domestic violence shelter
- Drug Treatment Center
- Educational Institution (dorm)
- Foster home
- Friend’s home
- Group home
- Homeless shelter
- Job Corp
- Mental Hospital
- On the street
- Other adult’s home
- Other Transitional living program
- Parent/Legal Guardian’s home
- Relative’s home
- Other
Other Living Situation
Have you ever been homeless?
- Yes
- No
Please explain
Criminal Arrest Status
Have you ever been arrested?
- Yes
- No
Have you ever been charged or convicted with a sexual offense?
- Yes
- No
Please list your arrest history:
Date Age Charge Commitment Length
Do you owe restitution, fines, or have outstanding court fees?
- Yes
- No
How much?
Health Information
Do you have TennCare?
- Yes
- No
Do you have your TennCare Card?
- Yes
- No
Do you have any significant health problems?
- Yes
- No
Please specify
Are you currently taking medication?
- Yes
- No
Please list your medication and reason you take the medication.
Medication Dose Reason for the medication
Do you have an established medical provider?
- Yes
- No
Do you have an established dentist?
- Yes
- No
Do you have allergies?
- Yes
- No
Please specify your allergies.
If given a drug test today would you pass?
- Yes
- No
Are you willing to take a drug test to enter or to remain eligible for housing?
- Yes
- No
Mental Health Information
Have you been diagnosed with anything concerning mental health?
- Yes
- No
Please specify
Have you in the past or currently experienced suicidal thoughts or ideations?
- Yes
- No
Have you ever attempted to commit suicide?
- Yes
- No
If yes, what was the action?
Do you have an established mental health provider?
- I have an established mental health provider
Mental Health Provider’s Name & Phone Number
Trauma Screening
Please check all that apply
- Neglect
- Domestic Violence
- Physical assault/abuse
- School violence
- Sexual assault/abuse
- Community Violence
- Emotional abuse
- Extreme interpersonal violence
- Bullied
- Human trafficking: Labor
- Human trafficking: Sex
- Identify Theft
- Robbed
- Stalking/Harassment
- Survivor of Homicide Victims
- Teen Dating Victimization
- Vehicular Victim (hit and run)
- Hate Crime Victim
- Kidnapped
- Other
Other:
Character References
Please list three adult references (teachers, employers, counselors, etc.)
Name Phone Number Relationship
List one family or emotional support
Name Address Phone Number Relationship
Essay Questions
What do you know about the housing program and what interests you about it?
What steps have you taken to prepare yourself to participate in the transitional housing program?
In the coming year, how will you prepare yourself for life after this housing opportunity?
What are your personal goals in the next 12 months?
Write a 100-word essay below describing yourself.
Certify*
- I certify that the above information on this application is true and correct.
Signature*
Today’s Date
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Date	Age	Charge	Commitment Length

Medication	Dose	Reason for the medication

Name	Phone Number	Relationship

Name	Address	Phone Number	Relationship

Housing Application

Transitional Housing Application

Financial Information

Employment Information

Education Information

Living Situation

Criminal Arrest Status

Health Information

Mental Health Information

Character References

Essay Questions

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