HALO Transition Living Program

APPLICATION YOU MUST COMPLETE ALL THREE SECTIONS FOR YOUR APPLICATION TO BE CONSIDERED Date: ____________________ Name: _____________________________________________________ SS#: _______________________ Date of Birth: ____/____/_______ Age: ______ Gender: Female___ Male___ Marital Status (circle all that apply):

Single

Married

Domestic Partner

Divorced

Separated

Widowed

Where are you living right now? (circle one): House/Apt.

Friends

Relatives

Shelter

Hotel

Street

Car

Other: ____________________

Address: __________________________________________________________________________________________ Street/PO Box City State Zip Code Phone # where we can reach you: ( Other phone #: (

) _________________________________

)_____________________________

How long have you been staying there? ______________ Where do you sleep (bed, couch, floor)___________________ how many people live there ___________________ how long are you allowed to live there? _______________________

I am going to list types of places people sometimes sleep. Please tell me which of these you have sleept at in the past 5 years: o


(how long?_______________________)

o

A friend’s House (how long? _________________)

o

Street or Sidewalk (how many times? __________)

o

Car, Van or RV
(how often?

Have you applied to this program before?

_________________)

Yes

No

o

A Park (how often? ________________________)

o

The woods, a field, or a riverbed? (how often? _________________________________________)

o

Other (SPECIFY): __________________________

When? _________________________________

What happened? ___________________________________________________________________ How did you hear about the HALO TLP?___________________________________________________ Do you know anyone who has been in THIS program? Yes No If yes, who? _____________________ What is your relationship to this person? ____________________________________________________ Page 1 of 10

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Is this a positive relationship? _____________________________________________________________ How long have you known this person? _____________________________________________________ What are your reasons for applying to the HALO TLP? Please explain circumstances:______________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Have you ever been in any other independent living programs?

Yes

No

If yes, where and when? _____________________________________________________________ Why did you leave that program? ______________________________________________________ _________________________________________________________________________________ Please list a reference from this program? (no peers) ______________________________________ If you are accepted into this program and you are not from this area (Jefferson City, MO), describe how comfortable you will feel working on goals for work and school for the duration of the program (18 months), in an area you are unfamiliar with: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ List three things you like about yourself: ______________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ List three things about yourself that you feel need improvement/attention: ____________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Education (check all that apply): ___ Some High School (current grade _______ )

____ High School Graduate ____GED

___ Some College (area of study:___________________________)

____Trade/Skill School

____ Other: ______________________________

___ IEP or Special Ed classes

Names of School(s)

Year Graduated / Attended

High School/GED: ______________________________________________________

_____________

College/Trade School: ___________________________________________________

_____________

Other: _________________________________________________________________

_____________

Page 3 of 10 Problems you have had in school: _____________________________________________________________________________ _________________________________________________________________________________________________ What helps you do better in school? (ie, tutoring, extra support, encouragement) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Family Mother’s name (first & last) _______________________________________________ Phone ___________________________ Address (city, state, zip) ____________________________________________________________________________________ Are you currently living with your mother?

Yes

No

If not, why can’t you live with her and when was the last time you saw her? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Do you still have contact with her? __________________If yes, how often? ___________________________________________ Father’s name (first & last) ___________________________________________________ Phone _________________________ Address (city, state, zip) ____________________________________________________________________________________ Are you currently living with your father?

Yes

No

If not, why can’t you live with him and when was the last time you saw him? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Do you still have contact with him? __________________If yes, how often? ___________________________________________ Brothers / Sisters names and ages: ________________________________________________________________

_________________________________________________________________________________ Your children:

Name _______________________________________Age _______________ Female ______ Male _______

Name of Child’s father/mother

______________________________________

Is the other parent of your child involved in your child’s life? Yes _____ No______ If yes, how? __________________ _________________________________________________________________________________________________ Name _______________________________________Age _______________ Female ______ Male _______ Name of Child’s father/mother

______________________________________

Is the other parent of your child involved in your child’s life? Yes _____ No______ If yes, how? __________________ _________________________________________________________________________________________________ Do you have family members who support you and your goals? Yes

No

Page 4 of 10 Do you have family members or friends who pressure you to do things you do not want to do?

Yes

No

Emergency Contacts List emergency contact names and phone numbers. If you have a child, list the child’s other parent and/or a relative of the child as an emergency contact: Name ______________________________________ Phone # ___________________________ Relationship ________________ Name ______________________________________ Phone # ___________________________ Relationship ________________ Name ______________________________________ Phone # ___________________________ Relationship ________________ Who is your legal guardian(s)? __________________________________________ Relationship to you _____________________ Legal Guardian(s) phone # (

)_____________________

Have you ever had a Case Worker? Yes No Phone # ( ) _____________________

If yes, Name: ______________________________________________

Do you have a current Case Worker? Yes No Phone # ( ) _____________________

If yes, Name: ______________________________________________

Name of Social Service office of social worker (DFS, SRS, City and State): ___________________________________________

To get a sense of what you have been through, please answer the following questions honestly: Health In the past year, have you been in the emergency room?

Yes

No

If yes, how many times? ______ What for? _____________

________________________________________________________________________________________________________ (Females) Are you pregnant? Yes

No

If yes, how far along are you? ____________________________________________ When is your due date? _________________________________________________

If pregnant, are you getting prenatal care?__________

If yes, where? _______________________________________

How long have you been getting prenatal care? ____________________________________________________________ Have you spoken to a professional about the different options? _______________________________________________ Health concerns / problems: __________________________________________________________________________________ Medications: ___________________________________________________ Do you have any allergies?

Name of Physician _________________________

Yes No If yes, what? _____________________________________________________________

Concerns about sexually transmitted diseases? Yes No __________________________________________________________

Substance Use Do you smoke cigarettes? Yes

No

If yes, how much per day? _______________________

How long have you smoked? _____________________ When was the last time you used drugs and/or alcohol? _____________________________________ What drug / alcohol do you use most often? ________________________ How frequently? _______________________

Page 5 of 10 Have you ever received substance abuse treatment? Yes No

If yes, where and when?

_________________________________________________________________________________________________________ Have you ever relied on drugs or alcohol to help you cope with life circumstances? Yes No

If yes, when and how often?

_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Legal Have you ever been arrested? (DWI, bad checks, assault, etc.) Yes

No

If yes, why were you arrested? ________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Have you served time in jail?

Yes No

If yes, how long?_________________ Why? ________________________________

_________________________________________________________________________________________________________ Do you have any pending tickets (speeding / parking, etc.)? ____Yes ____No Do you have any warrants out?

Yes

No

What for? _______________________________

What for?____________________________________________________________

Are you currently on parole, probation, or diversion? Yes No

How many months / years left? __________________________

Parole/Probation Officer: ________________________________________ Phone Number: _______________________

Mental Health Have you been in counseling?

Yes

No

Therapist / program name: _____________________________________________

What problems were you working on? __________________________________________________________________ Have you ever been in a mental health hospital or treatment facility?

Yes

No

When / Hospital name: ______________________________________________________________________________________ What problems were you working on? __________________________________________________________________ Medications you have tried: __________________________________________________________________________________ Are you currently receiving any mental health services?

Yes

No

If yes, what? _____________________________________________________________________________________________ Medications you are currently taking: __________________________________________________________________________ Do you have at least a month’s supply of your current medications? __________________________________________________ Have you ever had thoughts of suicide?

Yes

No

If yes, have you ever acted on those thoughts? __________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Have you ever tried to self-harm?

Yes

No

If yes, where/what happened?________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Page 6 of 10 Have you ever been in a drug or alcohol program?

Yes

No

If yes, when? ______________________________________

Where: ___________________________________________________________________________________________ AA Participant? Yes

No

NA Participant?

Yes

No

Transportation Do you have a driver’s license? Yes

No

If no, do you have your permit?

If yes, _____________________________________ MAKE Plate # ____________________________________

Yes No

Do you have a car?

____________________________________ MODEL

Yes

No

____________________ COLOR

Insurance Co Name: _____________________________________

Do you have experience using the Jeff City Bus System? Yes Would you be willing to use the Jeff City Bus? Yes

No

No

If no, why? ___________________________

Job History (Include last 3 years): Dates

Company Name

Pay Rate

Duties

Reason for Leaving

Income (Job, Child support, DFS, SRS, SSI, etc. If child support is owed to you, please list monthly total amount.) Source

Amount (weekly / monthly)

Employment Income: Food Stamps: TANIF: Other:

Do you have enough money to meet all of your expenses on a monthly basis? Do you have any family members or friends who support you financially? Yes

Yes No

No

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If yes, who and in what way? _______________________________________________________________ Do you currently owe an individual or an organization (such as a bank or a landlord, etc.) money? Yes No If yes, who and how much? ________________________________________________________________ Is there anyone who thinks you owe them money?

Yes

No

If yes, who? ________________________

Part II Social Skills On a scale of 1-5 (1=Poor to 5=Best) how would you rate yourself at the following:

Wake up on your own: ______ Laundry: _____

Keeping our house/space clean: ______

Being on time: ______

Personal hygiene: ______

Getting along with others: ______

Independent Living Skills On a scale of 1 to 5, (1=Poor to 5=Best) rate your ability to:

Purchase food: ______

Budget money: ______

Prepare well balanced meals______

Purchase clothing: ______

Take care of others: ______ Use banks: ______

Find jobs: ______

Hold jobs: ______

Use public transportations: _____

Use hospital: ______

Library: ______

Knowledge of colleges: ______

Use computer: ______

Car maintenance: ______

Being organized: ______

Problem Solving How do you deal with your anger? ___________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ How do you deal with peer pressure? _________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ How do you deal with stress? _______________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

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How do you deal with authority figures? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ What do you do with your free time? _________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ What do you do when you are alone? _______________________________________________________________________________________ _______________________________________________________________________________________

References By listing names and phone numbers below, you are indicating that you agree to allow us to contact anyone listed as a reference to aid in our decision to accept you into the program. Please do not list family members or friends. List persons from other programs you have been in, counselors, school personnel, employers, etc. Name 1) _______________________

Relationship ____________________

Phone # ( ) ___________________________

2) _______________________

___________________

(

) ___________________________

3) _______________________

___________________

(

) ___________________________

Documents

Please provide copies of the following with this application (HALO can make copies for you

if you bring these items in person to the HALO Center. You will need to call the HALO Center ahead of time and make an appointment to do this). If you are not able to provide these documents please explain why? 1. Birth Certificate 2. Driver’s License and current insurance card (if applicable) 3. Social Security card (for yourself and any children you have)

_______________________________________________________________________________________

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By signing below, I agree to the application process; I agree that all of the information on this application is true; and I agree to allow my references to be checked.

________________________________________________________ Applicant Signature

__________________________ Date

Part III This task is part of the Transitional Living Program (TLP) application process. The purpose of this document is for you to tell the intake staff about yourself. This document is used to help the intake team make a decision about whether you are appropriate for the program. This document should be neatly written or typed. You are encouraged to give as much detail and explanation in your social history as possible. Below is a description of things that should be included in your social history, you may include any additional information. Housing: Are you currently living with your biological mother, father, or a family member? If not, describe in detail why you cannot live with your biological mother, father, or family member. Describe your current living situation and how the last six months have been for you. General Information: Where were you born? Where have you lived and with whom have you lived? How long have you lived in each place? Mental Health: Are you currently being seen by a therapist, counselor, or psychiatrist? Do you have any diagnosis? If not, do you want to see a therapist or counselor? Why? Have you had any negative experiences with a therapist/counselor in the past? How did the therapist contribute to this? What could the therapist have done different? Have you ever had thoughts of harming yourself? Have you ever tried to harm yourself or someone else? If you saw a therapist/counselor on a regular basis, what would you want to work on? School: What schools have you gone to? How have your school years been so far; have you had any suspensions or expulsions? What school are you currently enrolled in? If you are not enrolled in school please explain why? If you are not enrolled anywhere, are you willing to return to school for either your GED or diploma? Have you ever been in a learning disorder or behavioral class? Relationships: Describe your family and friends. Who are you closest with and why? Who do you not get along with and why? Are you currently in an abusive relationship?

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Whom do you identify as your primary support system? Name or describe the people you identified as your support system. What are your strengths as a friend? Spiritual: Do you attend a church? Do you attend another religious organization? Is spirituality important to you? Legal Issues: Have you had any trouble with the law? Do you have any pending court cases? Do you have any outstanding court fees or back child support? Substance Abuse: Do you use drugs or alcohol? If you do use, do you feel like it is a problem for you? When and why did you start using? If you are not currently using what was your motivation to stop? How are you going to maintain sobriety? Free Time: What hobbies do you enjoy or what hobby would you like to learn about? How do you spend your free time? Goals: What are your plans for the future? Do you know how you are going to achieve your goals? Resources: Please list out any services you are currently receiving from other agencies, programs, or organizations

When you have completed all sections and you have all of the documents noted above, return these to the HALO Learning Center or a HALO representative. * Partial or incomplete applications will not be considered. The HALO Learning Center is located at 1015 E. Atchison, Jefferson City, MO 65101. *If we are away from the HALO Center at your time of visit, please fold and place your application in the mail slot next to the Common Ground’s door. Please do not leave original copies of your birth certificate, social security cards, or driver’s license with your application. HALO will not be liable for lost person documents. All applications are reviewed by the HALO Board on a monthly basis. After review of your application, a HALO representative will contact you at the number you listed in your application.

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If you have any questions about the application or the HALO TLP, please contact Lauren Bateman at [email protected] or 573-418-9912