HALO HOUSING APPLICATION

YOU MUST COMPLETE ALL THREE SECTIONS

FOR YOUR APPLICATION TO BE CONSIDEREDDate: ____________________

Name: _____________________________________________________ SS#: _______________________

Date of Birth: ____/____/_______ Age: ______ Gender: Female___ Male___

Marital Status (circle all that apply): Single Married Domestic Partner Divorced Separated Widowed

Where are you living right now? (circle one):

House/Apt. Friends Relatives Shelter Hotel Street Car Other: ____________________

Address: __________________________________________________________________________________________ Street/PO Box City State Zip Code

Phone # where we can reach you: ( ) _________________________________

Other phone #: ( )_____________________________

How long have you been staying there? ______________ Where do you sleep (bed, couch, floor)___________________

how many people live there ___________________ how long are you allowed to live there? _______________________

I am going to list types of places people sometimes sleep. Please tell me which of these you have sleep at in the past 5 years:

o A Shelter(how long?_______________________)

o A friend’s House (how long? _________________)

o Street or Sidewalk (how many times? __________)

o Car, Van or RV(how often? _________________)

o A Park (how often? ________________________)

o The woods, a field, or a riverbed? (how often? _________________________________________)

o Other (SPECIFY): __________________________

Have you applied to this program before? Yes No When? _________________________________

What happened? ___________________________________________________________________

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How did you hear about the HALO Housing?

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Do you know anyone who has been in THIS program? Yes No If yes, who? _____________________

What is your relationship to this person? ____________________________________________________Is this a positive relationship? _____________________________________________________________How long have you known this person? _____________________________________________________What are your reasons for applying to the HALO Housing? Please explain circumstances:

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Have you ever been in any other independent living programs? Yes No

If yes, where and when? _____________________________________________________________

Why did you leave that program? ______________________________________________________

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Please list a reference from this program? (no peers) ______________________________________

If you are accepted into this program and you are not from this area (Kansas City, MO), describe how comfortable you will feel working on goals for work and school for the duration of the program (18 months), in an area you are unfamiliar with: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List three things you like about yourself: ______________________________________________________

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List three things about yourself that you feel need improvement/attention: ____________________________

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Education (check all that apply):

___ Some High School (current grade _______ ) ____ High School Graduate ____GED ____Trade/Skill School

___ Some College (area of study:___________________________) ____ Other: ______________________________

___ IEP or Special Ed classes

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Names of School(s) Year Graduated / AttendedHigh School/GED: ______________________________________________________ _____________

College/Trade School: ___________________________________________________ _____________

Other: _________________________________________________________________ _____________

Problems you have had in school: _____________________________________________________________________________

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What helps you do better in school? (ie, tutoring, extra support, encouragement)

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FamilyMother’s name (first & last) _______________________________________________ Phone ___________________________

Address (city, state, zip) ____________________________________________________________________________________

(If not living with parents) When did you see your mother last? _________________________________________________________________________________________________________

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Do you still have contact with her? __________________If yes, how often? ___________________________________________

Father’s name (first & last) ___________________________________________________ Phone _________________________

Address (city, state, zip) ____________________________________________________________________________________

(If not living with parents) When did you see your father last? _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Do you still have contact with him? __________________If yes, how often? ___________________________________________

Brothers / Sisters names and ages: ________________________________________________________________

_________________________________________________________________________________Your children: Name _______________________________________Age _______________ Female ______ Male _______

Name of Child’s father/mother ______________________________________Is the other parent of your child involved in your child’s life? Yes _____ No______ If yes, how? __________________

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Name _______________________________________Age _______________ Female ______ Male _______

Name of Child’s father/mother ______________________________________Is the other parent of your child involved in your child’s life? Yes _____ No______ If yes, how? __________________

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Do you have family members who support you and your goals? Yes No

Do you have family members or friends who pressure you to do things you do not want to do? Yes No

Emergency ContactsList emergency contact names and phone numbers. If you have a child, list the child’s other parent and/or a relative of the child as an emergency contact:

Name ______________________________________ Phone # ___________________________ Relationship ________________

Name ______________________________________ Phone # ___________________________ Relationship ________________

Name ______________________________________ Phone # ___________________________ Relationship ________________

Who is your legal guardian(s)? __________________________________________ Relationship to you _____________________

Legal Guardian(s) phone # ( )_____________________

Current Case Worker Name ______________________________________________ Phone # ( ) _____________________

Name of Social Service office of social worker (DFS, SRS, City and State): ___________________________________________

To get a sense of what you have been through, please answer the following questions honestly:

HealthIn the past year, have you been in the emergency room? Yes No If yes, how many times? ______ What for? _____________

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(Females) Are you pregnant? Yes No If yes, how far along are you? ____________________________________________

When is your due date? _________________________________________________

If pregnant, are you getting prenatal care?__________ If yes, where? _______________________________________

How long have you been getting prenatal care?

____________________________________________________________

Have you spoken to a professional about the different options? _______________________________________________

Health concerns / problems: __________________________________________________________________________________

Medications: ___________________________________________________ Name of Physician _________________________

Do you have any allergies? Yes No If yes, what? _____________________________________________________________

Concerns about sexually transmitted diseases? Yes No __________________________________________________________

Substance UseDo you smoke cigarettes? Yes No If yes, how much per day? _______________________

How long have you smoked? _____________________

When was the last time you used drugs and/or alcohol? _____________________________________

What drug / alcohol do you use most often? ________________________ How frequently? _______________________

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Have you ever received substance abuse treatment? Yes No If yes, where and when?

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LegalHave you ever been arrested? (DWI, bad checks, assault, etc.) Yes No

If yes, why were you arrested? ________________________________________________________________________

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Have you served time in jail? Yes No If yes, how long?_________________ Why? ________________________________

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Do you have any pending tickets (speeding / parking, etc.)? ____Yes ____No What for? _______________________________

Do you have any warrants out? Yes No What for?____________________________________________________________

Are you currently on parole, probation, or diversion? Yes No How many months / years left? __________________________

Parole/Probation Officer: ________________________________________ Phone Number: _______________________CounselingHave you been in counseling? Yes No Therapist / program name: _____________________________________________

What problems were you working on? __________________________________________________________________

Have you ever been in a mental health hospital? Yes No When / Hospital name: ___________________________________

What problems were you working on? __________________________________________________________________

Medications you have tried: __________________________________________________________________________________

Medications you are currently taking: __________________________________________________________________________

Do you have at least a month’s supply of your current medications? __________________________________________________

Have you ever been in a drug or alcohol program? Yes No If yes, when? ______________________________________

Where: ___________________________________________________________________________________________

AA Participant? Yes No NA Participant? Yes No

TransportationDo you have a driver’s license? Yes No If no, do you have your permit? Yes No Do you have a car? Yes No

If yes, _____________________________________ ____________________________________ ____________________ MAKE MODEL COLOR

Plate # ____________________________________ Insurance Co Name: _____________________________________

Do you have experience using the Kansas City Bus System? Yes No

Would you be willing to use the Kansas City Bus? Yes No If no, why? ___________________________

Job History (Include last 3 years):

Dates Company Name Pay Rate Duties Reason for Leaving

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Income (Job, Child support, DFS, SRS, SSI, etc. If child support is owed to you, please list monthly total amount.)

Source Amount (weekly / monthly)

Employment Income:

Food Stamps:

TANIF:

Other:

Do you have enough money to meet all of your expenses on a monthly basis? Yes No

Do you have any family members or friends who support you financially? Yes No

If yes, who and in what way? _______________________________________________________________

Do you currently owe an individual or an organization (such as a bank or a landlord, etc.) money? Yes No

If yes, who and how much? ________________________________________________________________

Is there anyone who thinks you owe them money? Yes No If yes, who? ________________________

Part II

Social Skills

On a scale of 1-5 (1=Poor to 5=Best) how would you rate yourself at the following:

Wake up on your own: ______ Keeping our house/space clean: ______ Personal hygiene: ______

Laundry: _____ Being on time: ______ Getting along with others: ______

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Independent Living Skills

On a scale of 1 to 5, (1=Poor to 5=Best) rate your ability to:

Purchase food: ______ Budget money: ______ Prepare well balanced meals______

Purchase clothing: ______ Take care of others: ______ Use banks: ______

Find jobs: ______ Hold jobs: ______ Use public transportations: _____

Use hospital: ______ Library: ______ Knowledge of colleges: ______

Use computer: ______ Car maintenance: ______ Being organized: ______

Problem Solving

How do you deal with your anger? ___________________________________________________________

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How do you deal with peer pressure? _________________________________________________________

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How do you deal with stress? _______________________________________________________________

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How do you deal with authority figures?

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What do you do with your free time? _________________________________________________________

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What do you do when you are alone?

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References

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By listing names and phone numbers below, you are indicating that 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 or friends. List persons from other programs you have been in, counselors, school personnel, employers, etc.

Name Relationship Phone #1) _______________________ ____________________ ( ) ___________________________

2) _______________________ ___________________ ( ) ___________________________

3) _______________________ ___________________ ( ) ___________________________

Documents Please provide copies of the following with this application (HALO can make copies for you

if you bring these items in person to the HALO Center. You will need to call the HALO Center ahead of

time and make an appointment to do this). If you are not able to provide these documents please explain

why?

1. Birth Certificate

2. Driver’s License and current insurance card (if applicable)

3. Social Security card (for yourself and any children you have)

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

________________________________________________________ __________________________Applicant Signature Date

Part III

This task is part of the Scattered Housing application process. The purpose of this document is for you to tell the intake staff about yourself. This document is used to help the intake team make a decision about whether you are appropriate for the program. This document should be neatly written or typed. You are encouraged to give as much detail and explanation in your social history as possible. Below is a description of things that should be included in your social history, you may include any additional information.

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Introduction:Describe how the last six months have been for you.

General Information:Where were you born?Where have you lived and with whom have you lived?How long have you lived in each place?

Mental Health:Are you currently being seen by a therapist, counselor, or psychiatrist? Do you have any diagnosis?If not, do you want to see a therapist or counselor? Why?Have you had any negative experiences with a therapist/counselor in the past?

How did the therapist contribute to this?What could the therapist have done different?

Have you ever had thoughts of harming yourself?Have you ever tried to harm yourself or someone else?If you saw a therapist/counselor on a regular basis, what would you want to work on?

School:What schools have you gone to? How have your school years been so far; have you had any suspensions or expulsions?What school are you currently enrolled in?If you are not enrolled in school please explain why?If you are not enrolled anywhere, are you willing to return to school for either your GED or diploma?Have you ever been in a learning disorder or behavioral class?

Relationships:Describe your family and friends.Who are you closest with and why?Who do you not get along with and why?Are you currently in an abusive relationship?Whom do you identify as your primary support system?Name or describe the people you identified as your support system. What are your strengths as a friend?

Spiritual:Do you attend a church?Do you attend another religious organization?Is spirituality important to you?

Legal Issues: Have you had any trouble with the law?Do you have any pending court cases?Do you have any outstanding court fees or back child support?

Substance Abuse:Do you use drugs or alcohol?If you do use, do you feel like it is a problem for you?When and why did you start using?If you are not currently using what was your motivation to stop?How are you going to maintain sobriety?

Free Time:What hobbies do you enjoy or what hobby would you like to learn about?How do you spend your free time?

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Goals: What are your plans for the future?Do you know how you are going to achieve your goals?

When you have completed all sections and you have all of the documents noted above, return these to the HALO Home or email Lead Residential Supervisor Lauren Bateman at laurenbateman@haloworldwide.org . * Partial or incomplete applications will not be considered.

The HALO Home is located at 3519 Bennett Lane Jefferson, Missouri 65101. *If we are away from the HALO Home at your time of visit, please fold and place your application in the drop box at the front door. Please do not leave original copies of your birth certificate, social security cards, or driver’s license with your application. HALO will not be liable for lost person documents.

All applications are reviewed by the HALO Board on a monthly basis. After review of your application, a HALO representative will contact you at the number you listed in your application.

If you have any questions about the application or the HALO Housing Program, please contact HALO Center Staff at laurenbateman@haloworldwide.org or 816-590-4493.