YOUNG ADULT RESIDENTIAL APPLICATION
Thank you for applying to The Faine House
The Faine House welcomes your application for residency at our safe and secure facility located in Orlando, Florida, where our mission is young adult independence and stability. The following questions help us get to know you and discern whether our program can assist you in reaching your goals.
Name:
*
First Name
Last Name
US Citizen?
*
Yes
No
Gender:
*
Date of Birth:
*
Social Security Number:
*
Phone Number:
*
Email:
*
Young Adult's Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Monthly payment or rent
Current Status (Check One)
*
EFC/PESS
Foster History (Not EFC/PESS)
Unaccompanied/Homeless Youth
Other
Currently enrolled in school?
*
Yes
No
Last Grade Completed
Name & Location of School
Are you currently employed:
*
Yes
No
If yes, name of employer
Do you have a resume?
*
Yes
No
Are you aware, The Faine House is a 1-2 year program with expectations and requirements?
*
Yes
No
Are you aware there will be curfew, drugs, alcohol, visitor, and leaving grounds policies (that will be explained should you receive an interview)?
*
Yes
No
Are you aware the application process may take a few weeks and we do not accept every applicant?
*
Yes
No
Are you committed to developing healthy boundries, relationships, disciplines, and habits in your own life - in regards to your employment, education, and finances?
*
Yes
No
How do you see The Faine House program assisting you to achieve your short- and long-term goals?
*
What are your goals, and how do you see yourself accomplishing those within the next 2 years?
*
Do you understand this is a program that you are required to work through, and we are not emergency housing or like other traditional group homes?
*
Yes
No
Do you understand that there are daily, weekly, monthly & yearly expectations for you to meet?
*
Yes
No
Are you committed to staying at The Faine House for 2 years? This is a program requirement.
*
Yes
No
Are you committed to working towards full financial independence - a life without dependence on government subsidies?
*
Yes
No
Do you understand that if you have a previous history of a violent and/or sexual abuse crime or commit one while in The Faine House, you will be disqualified from The Faine House program?
*
Yes
No
Are you committed to working with mentors and referred services?
*
Yes
No
Have you ever lived in transitional housing?
*
Yes
No
If applicable, Referral Source - Agency Name:
Referral Source Contact:
First Name
Last Name
Referral Source Phone Number:
Please enter a valid phone number.
Referral Source Email:
example@example.com
Caseworker name (if applicable)
Do You Authorize the Release of Your Juvenile Case Management Records to The Faine House, Inc.?
*
Yes
No
I do not have a caseworker or previous case files
Caseworker Phone Number:
Do you currently receive SNAP benefits?
*
Yes
No
If so, amount you receive:
Do you currently use drugs?
*
Yes
No
If yes, what types of drugs do you use?
Frequency:
Date of last use:
-
Month
-
Day
Year
Date
Have you been hospitalized due to drugs or alcohol - this includes for an accident caused by drugs that you or someone else was taking at the time?
*
Yes
No
If yes, please explain:
If it was an overdose, which substance?
What was the treatment required?
Have you ever been arrested?
*
Yes
No
If yes, list charges:
Were you convicted?
Yes
No
Have you ever been in jail or a detention home?
Yes
No
If yes, when & where?
Have you ever been adjudicated dependent?
Yes
No
Have you ever been adjudicated delinquent?
Yes
No
If so, in what county and state?
Probation Officer:
First Name
Last Name
Probation Officer's Phone Number:
Please enter a valid phone number.
How long is your probation period?
Are you required to complete community service hours?
Yes
No
If yes, how many hours?
Any other conditions of the probation?
Date probation was completed:
-
Month
-
Day
Year
Date
Additional court obligations (fines, letters, etc.):
Have you ever had a psych evaluation?
*
Yes
No
If yes, when?
Have you recently experienced suicidal thoughts?
*
Yes
No
If yes, did/do you a plan to carry out suicide?
Have you ever thought of hurting yourself?
*
Yes
No
Have you ever been diagnosed with a depressive disorder?
*
Yes
No
Do you have special medical needs?
*
Yes
No
If so, please explain:
Medical Diagnosis - physical or mental:
Primary Care Physician:
Primary Care Phone Number:
Please enter a valid phone number.
Primary Care Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any known allergies?
*
Are you on any medications?
*
Yes
No
If so, name & frequency/dose:
Have you ever seen a Psychiatrist or Mental Health Therapist?
Yes
No
If so, what's your Psychiatrist/Psychologist Name?
Have you been hospitalized and/or admitted to a residential treatment facility?
Yes
No
If applicable, date you entered foster care:
-
Month
-
Day
Year
Date
Reason for removal from biological home:
Please Select
Abandonment
Neglect
Physical Abuse
Sexual Abuse
Parental Substance Abuse
Domestic Violence
Do you have any reliable mentors/supporters in your life - church leaders, relatives, teachers, case managers, GAL, adult friends, etc.?
Yes
No
If yes, what are your mentor's name(s)?
Do you have an emergency contact?
Yes
No
If yes, can you provide name & number:
Do you practice a religion?
Yes
No
If so, what religion & where do you practice?
Do you have a close, reliable friend your age?
Yes
No
If so, where do you know them from?
Where does he/she live?
Young Adult Printed Name:
Today's Date
-
Month
-
Day
Year
Date
I agree that I have completed this application in its entirety & in truth to the best of knowledge. I understand that dishonesty can hinder my approval.
Submit
Should be Empty: