To the Applicant:
Complete the above information and provide this form to your social worker. Your social worker must complete this form to evaluate your potential to succeed in the Transitional Housing Program. This form must be submitted along with the Transitional Independent Living Plan (TILP) for consideration.

To the Social Worker:
The individual named on the previously page has applied for the California Impact Coalition’s Transitional Housing Program. The placement committee requests that you provide detailed responses to the questions below, highlighting the applicant’s maturity, initiative, and readiness for transitional housing. Your insights are valuable in assessing their suitability for the program.