Housing Application

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Today’s Date

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):

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

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

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

Current or Last Employer End Date

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

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

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*