AGED OUT
Application

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Applicant Name*

First Middle Initial Last

Gender*

Other Gender (Please Explain)*

Date of Birth*

MM slash DD slash YYYY

Age*

Height*

Weight*

Ethnicity/Race*

Most Current Address*

Street Address City State ZIP Code

Address – County*

Who are you living with (family, foster home, friends, boyfriend)*

If not at a stable place, where are you sleeping?

Phone Contact*

Email Address

Driver's License or State ID #

Emergency Contact

Emergency Contact Name*

Relationship To You*

Emergency Contact Phone*

Emergency Contact Email*

How did you learn about Direction61:3?

Marital/Intimate Relationships

Marital Status*

Are you currently in a relationship?*

How long have you been with this person?*

Do you have one or more children?*

Do your children live with you?*

With whom do your child(ren) live and how often do you see them?*

Legal History

Do you have any current legal issues?*

Current legal issues (Please Explain)*

Have you ever been arrested for a crime?*

Arrests (Please Explain)*

Are you currently on probation?*

Probation Info

Reason for probation and date of offense*

When does probation end?*

What State/County?*

Name and number/email of Probation Officer*

How often do you report in?*

What type of reporting do you have to do?*

Spiritual

Did you grow up participating in any religious activities with your family or on your own?*

What faith/religion do you most belong to?*

Are you open to discussing and learning about faith as part of the Direction61:3 Program?*

Family Connections

Who took care of you growing up?*

What was it like growing up?*

(were there often times you were left alone, was your home life abusive, were some family members nurturing, was there domestic violence, were you responsible for other family members)

How many brothers/sisters do you have and where are they?*

Foster Care Experience

How long were you in foster care?*

What dates were you in foster care?*

How would you describe your foster care experience?*

Where are your parents/guardians today and what is your relationship like with them?*

Do you still have contact with any other family members? Please tell us who and what the relationship is like.*

Housing History

Are you currently without a permanent place to stay?*

How long can you safely stay where you are?*

Why is your current living situation no longer working for you?*

Have you tried to find other possible solutions such as contacting relatives or other placements?*

Education

Do you have a Diploma or GED?*

What is your last year completed in school and where?*

What are your future educational goals?*

Employment

Have you ever worked?*

Job 1 Details

Job Title*

Type of Work*

Dates worked (to/from)*

Hours per day*

Hours per week*

Pay Rate per hour/week/month*

Why did you leave?*

Do you have any other work history to add?

Yes, I’d like to add a 2nd job

Job 2 Details

Job Title*

Type of Work*

Dates worked (to/from)*

Hours per day*

Hours per week*

Pay Rate per hour/week/month*

Why did you leave?*

Do you have any other work history to add?

Yes, I’d like to add a 3rd job

Job 3 Details

Job Title*

Type of Work*

Dates worked (to/from)*

Hours per day*

Hours per week*

Pay Rate per hour/week/month*

Why did you leave?*

Physical Health

Please list current conditions, illness(es), injuries, pending follow-up visits*

Is there anything that limits you from working today?*

Do you have health insurance?*

Health Insurance Company*

Do you have your health insurance card?*

Do you have any mental health diagnoses?*

Mental health (please explain)*

Medications you are taking or have taken in the past*

Please list any medications and why they were prescribed. Also, are you currently taking them (why/why not), and the prescribing physician/clinic

Have you ever been hospitalized for trying to hurt yourself or others?*

If yes, when?*

How have you been feeling recently?(depressed, hopeless, sad, scared, confused, happy, hyper)*

Physical/Sexual Abuse, Neglect, or Mistreatment*

(have you experienced any type of abuse, neglect or mistreatment in your life or have you had any issues with yourself doing any of this type of behavior to others?) If yes, explain

Do you smoke? (cigarettes, cigars, pipes, vapes, or any other legal substances?)*

What do you smoke and how often?*

Substance Use/Abuse*

(prescription abuse, legal and street substances, current and past use, what used, first started using, attempts to stop, treatments, related legal issues, do you feel you have a problem?)

Sexual Addiction*

(have you ever sought treatment, felt like you needed help, or been aware that your sexual desires have caused problems in your life?)

What do you do when you're angry? Give examples of healthy ways to express anger*

What motivates you in life?*

What skills/tasks do you think you need assistance with to be successful?*

What obstacles do you feel are keeping you from reaching your goals in life? (educational, job, career, personal)*

Write a summary of what you understand the requirements to be at Direction61:3, strengths you have that will help you carry out the requirements, and why this specific program would be beneficial to you.*

Notice of Privacy Practices*

I acknowledge that I have received a copy of the Notice of Privacy Practices (NPP)

House Rules & Expectations*

I acknowledge that I have received a copy of the D61:3 house rules and program Expectations

Acknowledgement*

I acknowledge that all information in the application is true to the best of my knowledge

Signature*

Quick Links:

AGED OUTApplication

Emergency Contact

Marital/Intimate Relationships

Legal History

Probation Info

Spiritual

Family Connections

Foster Care Experience

Housing History

Education

Employment

Job 1 Details

Job 2 Details

Job 3 Details

Physical Health

AGED OUT
Application