Alle-Kiski Area HOPE Center, Inc

Referral Form

To be filled out by a representative from the agency referring the applicant

Alle-Kiski Area HOPE Center, Inc.

HOPE House Transitional Housing Program

P.O. Box 67 Tarentum, PA 15084

Phone: 724.224.7006 Fax: 724.224.5585/1123

Name of Applicant: ______Date: ______

Date of Birth: ___/___/___ Age: ______Social Security Number: ______

Children (Y/N) if yes, how many? ______

Ages & Gender of Children: ______

Name of Agency Referring: ______

Agency Contact Name & Number: ______

Is the applicant currently homeless (Y/N)?: ______

Is the applicant a survivor of Domestic Violence (Y/N)?: ______

Is the applicant currently receiving Mental Health services (Y/N)?: ______

If yes, from what agency & where?: ______

Is the applicant currently receiving Drug & Alcohol services (Y/N)? ______

If yes, from what agency & where: ______

How do you think the applicant would benefit from Transitional Housing Services?

______

Alle-Kiski Area HOPE Center, Inc.

HOPE House Transitional Housing Program

Application Form

Applicant’s Name: ______Date: ______

Date of Birth: ______Age: _____ Social Security Number: ______

Current Phone Number: ______

Please list children that would be moving into the Transitional Program with you (children 17 & under can enter the program):

Name: D.O.B. Age: Gender: With you presently?

1. ______

2. ______

3. ______

4. ______

5. ______

Education (check what applies to you):

_____ Did not finish High School _____ Some College

_____ GED _____ College Degree

_____ High School _____ Post College

_____ Trade/ Technical School

Sources of Income: (please list amount per month)

_____ Employed at $______Veteran’s Pension at $______

_____ SSI or SSD at $______Social Security at $______

_____ Food Stamps at $______Cash Assistance at $______

_____ Other (specify from where) ______$______

Other Benefits:

_____ Medical Assistance Program Name: ______

_____ Access Type: ______

_____ Other Please Specify: ______

If accepted into the Transitional Housing Program, you would be required to pay 30% of your income each month towards the program fee. Are you able to do this? (Y/N) _____

List Agencies/ Providers that are currently involved with you and/ or your children:

Agency: Service: Contact Person: Phone Number:

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

History of Abuse (if applicable):

Relationship to the abuser? ______

Do you have a current PFA (if yes, when does it expire)? ______

What is your current relationship with your abuser? ______

Is there a custody order for the abuser to see the children? ______

Has a PFA ever been served against you (Y/N)? _____ If yes, please explain.______

______

History of Addiction:

Have you ever had a problem with drugs or alcohol? ______

What is your drug/ drink of choice? ______

How often & how much do you use? ______

When was the last time you used? ______

Have you ever been in treatment & if so, who was your provider? ______

Are you currently in treatment & if so, who is your provider? ______

If you have past or current issues of drug/ alcohol abuse, are you willing to sign a “Contract

for recovery” upon entering the Transitional Housing Program? ______

Mental Health History

Did you ever have a mental health diagnosis & if so, what was it? ______

Do you have a current mental health diagnosis & if so, what is it? ______

Who is your provider? ______

Are you currently taking any kind of medications? ______

Please list the medications you are currently taking:

1. ______5. ______

2. ______6. ______

3. ______7. ______

4. ______8. ______

If you presently have or have had a mental health history and/ or history of addiction, are

you willing to address these with outside agencies on an on-going basis while in the Program? ______

Do you require any special assistance for daily living & if so, what accommodations are required?______

______

What do you feel you have accomplished during your stay at the Emergency Shelter or

at the facility you have been involved with (or during the time you have been homeless)? ______

______

What do you want to accomplish while in this Transitional Housing Program?

______

Where do you plan to be & what do you plan to be doing one year from now?

______

Please list 3 references (one may be a relative; caseworkers & service providers may be

used as well):

Name: ______Address: ______Phone: ______

*Please list a follow-up contact number in the case that your current phone number is

no longer available and your name comes up on the waiting list to contact for an interview.

Follow-up Phone Number: ______

The information I have provided above is true and complete to the best of my knowledge

and belief. I consent to the disclosure of information regarding financial and income verification related to my application for residency.

______

Applicant’s Signature Date

______

Staff Signature Date

Alle-Kiski Area HOPE Center, Inc.

HOPE House Transitional Housing Program

Transitional Housing Application Procedure

Participants within a 30-Day Emergency Shelter Program and/ or who are homeless, meeting the defined criteria, may be referred to the Alle-Kiski Area HOPE Center, Inc.’s Transitional Housing Program by emergency shelter staff or other service provider they are working with.

· Participants must be homeless or homeless survivors of domestic violence in need of supportive Transitional Housing.

· While in the One-Year Program, participants must either become employed and/ or continue some sort of education (within two months of entering) while working to obtain permanent housing and self-sufficiency within the year.

· Participants must be able to pay 30% of their income towards a monthly adjusted program fee.

· Participants must be willing to work within the structure of a Program with supportive services and rules and guidelines.

Interested applicants will fill out an application for the Program with the assistance of emergency shelter staff or other service provider. The emergency shelter staff /other service provider fills out the referral form. The applicant returns the completed application & referral form to the Alle-Kiski Area HOPE Center.

The application & referral form should be sent to the HOPE Center’s Coordinator of Transitional Housing (Fax: 724.224.5585/1123 or mailed to P.O. Box 67, Tarentum, PA 15084). Once received, the application will be reviewed and placed on the Program’s waiting list. Please contact the Coordinator after faxing or mailing an application in to verify that it was received.

Once an apartment becomes available, the waiting list will be reviewed and applicants will be contacted to set up an in-person interview at the Program site. After all applicants have been interviewed, a candidate will be selected.

December 2011