My Sister's House - Transitional Living Program Intake Application

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Email *

First and Last Name *

What is your date of birth? *

YYYY

Phone number *

Address *

What is your current marital status? *

Single

Committed relationship

Married

Divorced/separated

Widowed

Which race(s) do you identify?

African American/Black

White

Hispanic/Latin

Asian/Pacific Islander

Other:

Have you previously resided at My Sister's House? *

Yes

If you have previously resided at My Sister's House, when and why did you leave? (N/A if not applicable) *

What is your highest level of education? *

Elementary School

Middle School

High School Diploma/GED

Trade or Vocational Program

Bachelor Degree

Graduate/Post Grad Degree

Are you currently enrolled in school? *

Yes

Are you interested in furthering your education? *

Yes

What is your current employment status? *

Unemployed

Part-time employment

Full-time employment

If you are employed, please list your employer information (Business name, address, supervisor name, supervisor phone number)

Check the box of any benefits you are receiving? *

SSI/Disability

Child support

EBT/Food stamps

None

Required

Do you have any children in your custody? *

Yes

What is your current living arrangement? *

Emergency shelter

Transitional housing

Institution (hospital, inpatient, prison)

Family/friend

Hotel

Car

Unsheltered (outside)

Tell us more about incidents that led to your homelessness? *

Do you have a support system? (friends, family, sponsor, etc.) *

Yes

Do you have a history of drug/alcohol use? *

Yes

I am currently using drugs/alcohol

Have you ever attended a rehab program before?

Yes

Clear selection

Please check all the boxes that apply to you: *

I know how to balance a check book

I can operate a computer

I have difficulty reading and writing

I have trouble with my memory

I like to socialize and participate in group activities

I prioritize my health (mental and physical)

I can bathe/shower/use the restroom independently

I can walk/sit/stand/bend independently

I can do common chores (mopping, laundry, etc.)

I can climb onto a top bunk bed independently

Required

Have you ever been seen by a social worker, counselor, therapist, psychologist, or psychiatrist? *

Yes

I'm not sure

(Mental) Please check all the boxes that apply to you: *

I have little to no interest or please in doing things

I often feel down, hopeless, or depressed

I have trouble falling asleep, staying asleep, or sleeping too much

I often have little to no energy or feel tired

I often over eat or eat too little

I have trouble concentrating on things such as television or reading a newspaper

I often move or speak so slowly that other people have noticed

I am often fidgety or restless

I have thought that I would be better off dead

I have thought about hurting myself or someone else

I am easily angered

I have been diagnosed with a mental health disorder

I am currently taking medication for a mental health disorder

I am willing to see a licensed therapist

Required

(Physical) Please check all the boxes that apply to you: *

I have constant physical pain

I have concerns about my physical health

I take medication for a physical condition

I have a primary care physician

I have concerns with my teeth

I have a dentist

I have concerns with my vision/eyesight

I wear prescription glasses/contacts

I am willing to be connected to a primary care physician

Required

(Financial) Please check all the boxes that apply to you: *

I have a checking account

I have a banking account

I have a budget that I follow

I know my credit score

I have enough money to pay my current bills

I have been evicted from a home/apartment

I have rented or owned a home/apartment for at least one year at any time in my life

I have outstanding debt (utility, credit cards, car lease, etc.)

I have concerns about my finances

I am wiling to meet with a financial coach

Required

(Religion) Please check all the boxes that apply to you: *

I am a member of a church/group of worship

I would like to become a member of a church/group of worship

I am willing to join a church/group of worship

I do not identify with any religion/spirituality

Other:

Required

(Legal) Please check all the boxes that apply to you: *

I have no legal/criminal history

I have pending charges or upcoming court apperances

I have been convicted or imprisoned at any time in my life

Other:

Required

Please check all the boxes that apply to you: *

I can complete tasks in a timely manner

I have a plan/goal for my life

I take responsibility for my own actions

I am willing to participate in community service opportunities

I have identified areas of my life I want to improve

Required

Tell us more about your personal goals *

Are there any additional services you believe you will need to be successful at My Sister's House? *

Tell us more about why you chose My Sister's House *

Do you consent to My Sister's House verifying the information you have provided? *

Yes

Submit

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