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. Today’s Date Date Format: 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneWhose Phone Number Is Listed? My phone My friend’s phone Email Preferred Contact Method E-mail Text Mail Phone Call Birth Date Date Format: MM slash DD slash YYYY Do you have your original Birth Certificate? Yes No Social Security NumberDo you have your original Social Security Card? Yes No ReligionHow 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 Date Format: 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 ManagerI am or have been on probation Yes No Name of last Probation OfficerPhone number of Probation OfficerSpecial NeedsCheck all that apply Alcohol Abuse Developmental Disability Domestic Violence Victim Drug Abuse HIV/AIDS Mental Illness Physical Disability Financial InformationIncome 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 SourceAre you enrolled in Opportunity Passport at Youth Connections? Yes No Employment InformationEmployment 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 NameCurrent or Last Employer Job TitleCurrent or Last Employer Start Date Date Format: MM slash DD slash YYYY Current or Last Employer End Date Date Format: MM slash DD slash YYYY Hourly PayHave 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 InformationSchool Status Attending High School Attending Vocational School Attending Junior College Attending 4-Year College/University Attending Other Not Attending School Last grade completedName 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 SituationCurrent 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 SituationHave you ever been homeless? Yes No Please explainCriminal Arrest StatusHave you ever been arrested? Yes No Have you ever been charged or convicted with a sexual offense? Yes No Please list your arrest history:DateAgeChargeCommitment Length Do you owe restitution, fines, or have outstanding court fees? Yes No How much?Health InformationDo you have TennCare? Yes No Do you have your TennCare Card? Yes No Do you have any significant health problems? Yes No Please specifyAre you currently taking medication? Yes No Please list your medication and reason you take the medication.MedicationDoseReason 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 InformationHave you been diagnosed with anything concerning mental health? Yes No Please specifyHave 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 NumberTrauma ScreeningPlease 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 ReferencesPlease list three adult references (teachers, employers, counselors, etc.)NamePhone NumberRelationship List one family or emotional supportNameAddressPhone NumberRelationship Essay QuestionsWhat 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 Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
