Resident Application

Applicant Information

Name(Required)

First Last

Date(Required)

Phone(Required)

Alternate Phone(Required)

Email(Required)

Facebook Name

What is the best way to contact you?(Required)

Date of Birth(Required)

Age(Required)

Please enter a number from 1 to 100.

Gender(Required)

Marital Status(Required)

Where are you living right now?(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you been staying there?(Required)

Where do you sleep? (bed, couch, floor), how many people live there, how long are you allowed to stay there, etc?(Required)

Where did you live before that (last 3 places/placements)? How long were you there?(Required)

Have you applied to a TLP program before?(Required)

Yes

No

When and Where?(Required)

What Happened?(Required)

Have you ever been in an independent living program (ILP)??(Required)

Yes

No

When and Where?(Required)

Why did you leave the ILP program?(Required)

How were you referred to this TLP? (ILP skills trainer/DHS caseworker/Friend/Relative, etc)(Required)

Can you tell us how the last 6 months have been for you? Why are you seeking a TLP program?(Required)

Have you ever been in foster care? If so, for how long?(Required)

List three things you like about yourself(Required)

List three things about yourself that you feel needs improvement(Required)

Financial Assistance/Benefits

If you are receiving Social Security, SSI, Food Benefits, SNAP or any subsidies, benefits or housing assistance, please identify the source and monthly amount.

Clean and Sober Requirement

HWAM does not permit the possession or use of alcohol or other intoxicants or any illegal controlled substances (drugs) on the property. HWAM TLP considers marijuana to be a prohibited intoxicant. Residents are subject to random drug tests. If applicant is suspected of abusing alcohol/drugs, it could mean immediate discharge from the program/home.

Personal References:

By listing names and phone numbers below, you are indicating 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. Possible list should include persons from other programs you have been in, counselors, skills trainers, case managers, school personnel, employers etc.

Full Name

Relationship

Phone

Full Name

Relationship

Phone

Full Name

Relationship

Phone

Please note, if you are accepted to the TLP program, staff will ask you for forms of ID. If you have no forms of ID, let the staff know during your interview. Forms of ID include birth certificate, state ID, social security card, transcripts, medical records etc.

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

It is strongly encouraged that you call or email the TLP program to follow up on your application and see if they are scheduling interviews.

If you need help with this application, please call Hearts with a Mission. A staff can meet with you and assist you with the application.

Name

First Last

Date

Applicant Information

Education

Family & Support System

Emergency Contacts

Medical Information

Medications

Substance Abuse

Legal

Counseling

Risk Behavior

Abuse

Social & Independent Skills

Financial Assistance/Benefits

Clean and Sober Requirement

Contact HWAM

Locations

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