Resident Application

Transitional Living Center in Midland, TX

Build a Strong Foundation for Your Future

Once your application is complete, save it and email it to stephanie@basindreamcenter.org for review. She will contact you to schedule an interview. If it is determined that the program will be a good fit for you, the next step for intake will be a drug screening and background check. All applicants are assessed individually and acceptance is based on a case-by-case basis.

Complete and submit the application with the form below, filling out as much information as possible.

To access the fillable PDF or download the application, click the button below.

Build a Strong Foundation for Your Future

Resident Application Form

Applicant’s Name

Full Address

Phone #(s)

Full Social Security #

DOB

AGE

Ethnicity

Hispanic Non-Hispanic

Language Preference

English Spanish Other

Referral Sources

Parent/Guardian/Worker Name

Section I: Housing and Basic Needs – Current Situation

Do you have any dependents

Yes No

If yes, what is the relationship?

Do you have stable housing?

Yes No

If no, where did you sleep last night: (Select only one)

Homeless situation Place not meant for habitation Emergency shelter, incl. hotel/motel paid for w/ ES voucher or RHY-funded Host Home shelter Safe Haven

Institutional situation:

Foster care home or foster care group home Hospital or other residential non-psychiatric medical facility Jail, prison, or juvenile detention facility Long term care facility Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Not Applicable

Temporary and permanent housing situation: (If applicable)

Residential project or halfway house Hotel/motel paid for w/o ES voucher Transitional housing for homeless persons (incl. homeless youth or Host Home non-crisis) Staying or living in a friend’s room, apartment, or house Staying or living in a family member’s room, apartment, or house Rental by client, with GPD TIP housing subsidy Not Applicable

If you don’t have stable housing, what was the length of stay where you slept last night

Do you feel safe in your living situation? Yes

Do you feel safe in your living situation? No

If you don’t have stable housing, what is the approximate start date of homelessness

# Of times on the streets in the past 3 years (in emergency shelter ES or street homeless SH

Other needs

Do you receive

I do NOT receive ANY non-cash benefits

WIC- $ Amount of non-cash benefits

TANF (Transportation Services)- $ Amount of non-cash benefits

TANF (Child Care Services)-$ Amount of non-cash benefits

SNAP/Food Stamps - $ Amount of non-cash benefits

Other Sources/Amount of non-cash benefits

TOTAL AMOUNT OF NON-CASH BENEFITS: $

Are you covered by Health Insurance?

Yes No Need assistance with applying

If you selected anything other than "None", please list the policy number and the name of the policy holder: (Make this an optional question)

policy number

Policy Holder Name (as it appears on the insurance card)

Do you have a Monthly Income

Yes No

Private Disability Insurance-Monthly Amount

Child Support-Monthly Amount

Earned Income (currently have a job)-Monthly Amount

SSDI-Monthly Amount

SSI-Monthly Amount

TANF-Monthly Amount

Do you have a disability?

Yes No

If you have a disability, do you receive SSI or SSDI for that disability?

Yes No

If yes, is it expected to be long continued & indefinite duration & substantially impairs ability to live independently?

Yes No

If yes, how much monthly?

Start date of disability

Section II: Education

Does client read on grade level?

Yes No

If no, what grade level?

Last/highest grade completed

Is client currently in school?

Yes No N/A

If yes, where?

Current grade

Are they on an IEP?

Yes No

If yes, what for?

Are they experiencing any barriers?

Behind on credits

Other

If not in school, what is their educational plan?

What are their future educational goals?

College Trade School Career-tech

Other

Other educational issues

Section III: Employment/Vocational

Are you of job age (i.e., 16 or older)?

Yes No

If yes, which of the following best describes your situation?

If unable to work, why?

If you're not looking for employment, why

What are your employment goals?

Tell me about the jobs you have had in the past

What barriers do you feel you face in achieving employment goals?

Section IV: Health and Wellness

Do you have any specific medical conditions/diagnosis/injuries/illnesses/allergies?

Yes No

If yes, describe description of problem(s) and client’s ability to adjust to reported disorders or disabilities

Are there any conditions in the environment that have affected your wide range of health, functioning, or quality of life?

Yes No

(Social determinants of health - i.e., lack of economic stability, lack of quality education, lack of access & quality of healthcare, lack of food, lack of safe affordable housing, lack of transportation, neighborhood violence, different kinds of pollution or exposure to toxins like 2nd hand smoke or loud noises)

Does client report any medication allergies or adverse reactions?

Yes No

If yes, note what medication & the reaction it causes

If client has allergies or adverse reactions, do they have an EpiPen (auto injector) in their possession?

Yes No

If client has asthma, do they have an inhaler?

Yes No Not Applicable

Please list any food allergies

Please list any dietary requirements

Do you have regular eating habits?

Yes No

If no, please describe

In the past 90 days, how often have you had access to an adequate amount of food from the major food groups approximately?

25% of the time 50% of the time 75% of the time Over 75% of the time

If you have any other health needs, please explain

If yes, what referrals need to be made?

Do you have a Dr.?

Yes No

If yes, who & phone #

If not, what do you do when you are sick?

Will you pass a drug test?

Yes No

If not, what do you have in your systemIf not, what do you have in your system?

Are you now or have you ever been sexually active?

Yes No

If sexually active, do you use protection?

Yes No

If yes, what kind?

Are you currently pregnant?

Yes No

If yes, due date

Do you have any children?

Yes No

Complete Information Below

If yes

Sex

M F

Age

Live with you?

Yes No

Name

Sex

M F

Age

Live with you?

Yes No

Other

Have you ever received anything in exchange for having sexual relations with another person, such as money, food, drugs, or shelter?

Yes No

If yes, has it been within the past three months?

Yes No

How many times?

Were you ever made or persuaded to have sex in exchange for something?

Yes No

If yes, has it been in the past three months?

Yes No

Suicide Assessment

Are you thinking about suicide?

Yes No

If yes, take immediate action by following agency procedures and document steps taken below

Homicidal (harm to others) Assessment

Are you thinking about homicide or hurting someone else?

Yes No

If yes, take immediate action by following agency procedures and document steps taken below

Check All That Apply

Are you currently receiving mental health services anywhere else?

Yes No

If yes, where?

Any history of receiving mental health services elsewhere?

Yes No

If yes, where?

Substance Abuse Screening

Any history of drug/alcohol use, risk?

Yes No

If yes, Drug of Choice

Amount Used

Frequency

Age of 1st Use

Last Used Date

Legal Issues / Legal Status

Ever been to county jail?

Yes No

If yes, how many times

Has client been arrested in the past 30 days?

Yes No

If yes, how many times?

What were they arrested for?

Has client been arrested in the past 12 months?

Yes No

If yes, how many times in the past 12 months?

What were they arrested for?

Are you court involved?

Yes No

If yes

DHS Juvenile Bureau Office of Juvenile Affairs Municipal Court

If yes, Worker Name & Phone#

Have you ever been in CPS custody?

Yes No

If yes, when (what year) and why?

Time involved

less than 1 year 1 – 2 years 3-5 or more

If less than 1 year how many months

Have you ever been in Juvenile Detention custody?

Yes No

If yes, when, and why?

Time involved

less than 1 year 1 – 2 years 3-5 or more Not Applicable

If less than 1 year how many months

Has the state/CPS ever come to your house to check on you and your family?

Yes No

How many different homes, shelters or group homes have you stayed in? (Must be a # i.e., 3)

Have any of your family members ever been incarcerated?

Yes No

If yes, who and why?

Are you now or have you ever been gang involved or gang associated?

Yes No

If yes, what gang?

Are you currently considered a runaway?

Yes No

Section V: Permanent Connections

What are your sources of support? (client’s supports that assist in achieving goals of independence & productivity and facilitate integration into the community)

Other

Who do you rely on the most for support?

Are you involved in any activities, groups, organizations? (i.e., band, sports, clubs at school, church youth group, etc.)

Yes No

If yes, what activities/groups/organizations?

Strengths, Needs, Abilities (and/or Interest), Preferences, & Liabilities
Describe the client’s perceptions concerning their personal strengths, needs, abilities, & preferences as they relate to their overall functioning in the community. Include any liabilities in these areas that needs to be addressed in the client’s treatment, as well as preferences for treatment.

Personality characteristics – i.e., trustworthy, caring, giving, confident, etc

Strengths:

What they need to work on or need in their life

Needs:

Things that hold them back or stand in the way – i.e., being on probation, neg. peers, etc.

Liabilities

You will have roommates. Will you have problems living and getting along with roommates?

Yes No

What might prevent you from getting along?

You will need to keep your room and bathroom clean, learn and prepare meals and clean up afterwards, and perform daily/weekly chores. Will you be willing to do that?

Yes No

A plan will be developed with and for you. You will meet with your Case Manager to discuss your progress and be given suggestions to help you achieve your goals. Will you be willing to follow this guidance provided to move forward?

Yes No

What qualities do you bring that will help you stay on track?

How would you describe yourself?

Besides educational and employment goals, what else can we help you with?

What are some things that are getting in the way of your goals?

What are your greatest strengths that would help you be successful in our program?

How did you hear about BDCO?

What else should we know about your situation in considering your application?

signature
"By typing your full name, you acknowledge that you are the person completing this form of your own accord and that their information submitted is accurate to the best of your knowledge."

Resident Application

Transitional Living Center in Midland, TX

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