JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Post-Graduation Transitional Support Program Application
After graduating from our 9 month program or similar program, women may be eligible for one of 3 Transitional Support
options:
● On-site aftercare in the program house house (Refuge for Women residents only)
● Transitional living/casework in Refuge for Women-managed housing
● Transitional care/casework while you live off site in housing of your choosing
Please note that acceptance into Transitional Support Program is upon approval by Refuge for Women leadership staff.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
PERSONAL INFORMATION
First Name
*
Your answer
Last Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Marital status
*
Choose
Single
Married
Separated
Divorced
Widowed
Current Address/Location
*
Your answer
Which Transitional Support Program Options are you applying for?
*
Aftercare (extension in current location for up to 3 months, only available for current Refuge for Women residents)
Transitional Living (Refuge for Women-managed housing/available at limited locations)
Transitional Care Program (does not include housing)
Required
If you selected Transitional Living, which location are you requesting? (We will try to accommodate your requested location based on availability)
Chicago
Kentucky
Las Vegas
North Texas
Texas Gulf Coast
Why did you select the option you did? Why do you want to enter the Refuge for Women Transitional Support Program?
*
Your answer
Please indicate your Refuge for Women program location (current location):
*
Choose
Kentucky
Illinois (near Chicago)
North Texas
Southern Nevada
Pittsburgh
Texas Gulf Coast
Non-Refuge for Women program
If Non-Refuge for Women program, please provide the name and location of other program (this is required to be considered for acceptance if non-RFW resident):
Your answer
Please list the dates you attended this program?
*
Your answer
(Non-Refuge only) Phone number where you can be reached:
Your answer
(Non-Refuge only) Email address where you can be reached:
Your answer
What recovery meetings do you attend regularly?
*
Your answer
Which church fellowship are you a part of?
*
Your answer
Do you have underage children?
*
Yes
No
If you have underage children, what are your plans for their care if you are accepted into the Transitional Support Program? Please include custody arrangements.
Your answer
What are your hopes for contact with family members while in the program?
*
Your answer
Please list three goals you want to accomplish while in the Transitional Support Program:
*
Your answer
EDUCATION AND WORK
What are your plans for work while in Transitional Support Program?
*
Your answer
What are your expected expenses during your time in Transitional Support Program?
*
Your answer
Please list your savings plan for your time in Transitional Support in timeline format (for example, at month 1 I will have saved___; at month 6 I will have saved___; etc.):
*
Your answer
What are you plans for education (if needed) in Transitional Support Program?
*
Your answer
MEDICAL INFORMATION
List all medications you are currently taking, dosage, and reason for taking:
*
Your answer
Please list any medical procedures you are anticipating during your time in Transitional Support Program (include both medical and dental):
*
Your answer
TRANSPORTATION
What are your plans for transportation? (Please note that rides from others will need approval from RFW)
*
Your answer
Do you understand that transportation needs in the Transitional Support Program are your responsibility? This includes medical appointments, therapy or counseling sessions, refilling medications, and to and from work or school.
*
Yes
No
RECOMMENDATION AND ATTESTATION
Please list name and contact information for program leader who will write your letter of recommendation (required for non-RFW applicants):
Your answer
The program guidelines will be provided to you prior to approval to enter to the program for your review and signature of agreement to abide by the program expectations.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Refuge For Women.
Report Abuse
Forms