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Transitional Housing Program
Thank you for taking the time to complete our THP application.
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Transitional Housing Program Application
Begin
Where did you hear about us?
--Select--
--Select--
A friend told me
A friend told me
Facebook
Facebook
Twiiter
Twiiter
Google
Google
Next
Complete the following.
*Full Name
*Pronouns/Sexual Orientation
*Date of Birth
*Social Security Number
*Phone Number
*Email
*Current Address
*Do You Have Children
.
Yes
.
No
If Yes, list their names and ages:
Next
Social Worker Information
*Full Name
*Phone Number
*County
*Email
*Are you currently on probation or have been on probation?
.
Yes
.
No
If yes, provide the following:
Probation Officer Name
Phone Number
County
Email
Next
Referral Source
*Referring Person’s Name
Relationship
Agency
*Phone Number
*Email
Emergency Contact Information
*Full Name
Relationship
*Phone Number
*Email
Next
Current Housing Situation
*Do you have safe, stable housing?
.
Yes
.
No
If no, do you need emergency shelter?
.
Yes
.
No
*What best describes your current housing situation?
.
Living with someone and paying rent
.
Renting your own space
.
Participating in a THPP program
.
Unstable housing
*Have you ever lived with a roommate?
.
Yes
.
No
If yes, please describe that experience:
Placement Preferences:
*Preferred neighborhood or city:
*Any unsafe neighborhoods or cities for you:
*Ethnic Identity
.
American Indian or Alaskan Native
.
Black, non-Hispanic, including African
.
Mexican American, Mexican, Chicano
.
Central American
.
South American
.
Cuban
.
Puerto Rican
.
Other Latino
.
Chinese
.
Japanese
.
Korean
.
Laotian
.
Vietnamese
.
Filipino
.
White
.
Pacific Islander
Next
Education and Employment
*Have you obtained any of the following?
.
GED
.
High School Diploma
*Current Education Status:
.
In high school
.
Community College
.
4-Year College
.
Enrolled in a GED program
.
Enrolled in adult education
*Are you interested in enrolling in school?
.
Yes
.
No
If enrolled, what school are you attending?
Current Employment Status:
Are you currently employed?
.
Yes
.
No
If Yes, Please list your employer and position.
If unemployed, what is your primary source of income?
Financial Skills:
*Do you have experience creating and following a monthly budget?
.
Yes
.
No
*Are you able to pay bills on time?
.
Yes
.
No
*Do you have a credit card?
.
Yes
.
No
*Do you have a bank account?
.
Yes
.
No
Transportation and Mobility:
*Do you know how to use public transportation?
.
Yes
.
No
*Do you own a vehicle?
.
Yes
.
No
If yes, what kind?
*Do you have any pets?
.
Yes
.
No
Next
Final
Personal Goals
How will entering the Transitional Housing Program help you achieve your short-term or long- term goals?
By signing below, I certify that the information provided is accurate and complete to the best of my knowledge. I also consent to the release of my court report and understand that this information will only be used to determine my eligibility for the program.
Applicant Signature
Date
Finish
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