Transitional Housing Application

Applicant Information

How did you hear about Loving Grace?

Message Phone (if different):

Do you have your original Birth Certificate?

Yes No

Social Security Number:

Do you have your original Social Security Card?

Yes No

Do you have a valid Driver's Liscense or Permit Driver's License or Permit Number:

Yes No

Have you ever been or are you in:

Foster Care Legal Guardianship Probation

Name last social worker, guardian or probation officer:

Number of person listed above, if current:

Demographic Information

Race (select all that apply):

Ethnicity:

Hispanic or Latino Non Hispanic or Latino

Priamary Language:

English Spanish Other

Check all that apply:

Currently Fleeing?

Yes No

Family Planning Information

How many children have you given birth to?

How many of these children live with you?

Do you have a child custody order?

Yes No

Are you currently pregnant?

Yes No

Are you currently on a form of birth control?

Yes No

If yes, what kind?

pill implant shot other

Relationship Information

Emergency Contact Information (Please provide at least one)

No Contact List: List anyone that you do not want contact with due to safety concerns:

Contact Information if known:

Parent/Guardian Information

Do you have a good relationship with your parent/guardian?

Yes No

If yes, please add contact information (if different than emergency contact)

Romantic Relationships

I am not in a relationship I am in a relationship

I am in a relationship

unmarried couple married

If in a relationship:

Financial Information

Income Sources (check all that apply):

Non-Cash Benefits (check any that apply):

Supplemental Nutrision Assistance Prgram (SNAP: Formerly Known as Food Stamps) Special Supplemental Nutrition Program for Women, Infants and Children (WIC) TANF Child Care Services TANF Transportation Services

Education and Employment Information

Student Status:

Current or Last School Attended:

Last grade Completed:

Employment Status:

Current or Last Employer:

Do you have significant physical or mental health problems that affect employability?

Yes No

If yes, please Explain:

Can you pass a drug test today?

Yes No

Are you willing to take a drug test to enter the program?

Yes No

Are you aware that you may be drug tested at any time during your residency to remain elegible to stay at Loving Grace?

Yes No

Please list any current medications you are taking:

Please list any allergies you have:

Current Living Situation:

Have you ever been Homeless?

Yes No

If yes, please provide dates:

Criminal History Informaiton

Have you ever been arrested?

Yes No

I have been arrested

Please List Any Arrest History:

I am currently on:

Probation Parole Not Applicable

Select the transitional program that you are applying for

Doris House
This program is designed to help young mother's continue working toward their goals while caring for thier child or regaining custody of their child. One of their goals will always include getting invlolved with Early Head Start and utilizing the recources they have available. Each resident will have thier own room that they will share with their own child(ren). Oglesby House
This program is designed to help young women learn to become independent and give them a safe space to stay while they learn the life skills they need to live on their own. All goals will be specific to each young women's needs. Each resident will have her own room and will have specific times where they are required to be in shared spaces to socialize or complete programming.

When selecting a program, please understand that both programs require you to pursue and make progress toward education and/or employment goals, along with all goals set by you during the intake timeline.

Doris House Applicants Only

If you chose to apply for Oglesby, please skip to Essay Questions

Does your child have an active father?

Yes No

If yes, please provide name and number

If no, who would take on this role to help you?

Does your child have a social worker?

Yes No Has in the past

Name last social worker:

Number of person listed above, if current:

Birth Date of child:

Child has original Birth Certificate

Yes No

Social Security Number of child:

Child has original Social Security Card

Yes No

Please list any medications child is taking:

Please list any allergies child has:

How did you hear about Loving Grace, what do you know about the program, and what questions do you have?

What are your personal goals for the next 6-12 months?

Describe a time when you disagreed with a rule (maybe at work, school, or a living situation). How did you approach the disagreement? What was the outcome?

Describe a time when a peer made you mad. What happened? What was the outcome?

Describe a situation when your stress level was very high. What did you do about it? What helped? What didn't help?

Describe an accomplishment that you are proud of.

What expectaions of the Loving Grace program do you have?

Write a short essay about yourself. What are your likes and dislikes? What do you want us to know about you?

I certify that all the information included in this application is both true and correct.

Transitional Housing Application

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Single Application
(Oglesby House Application)

Pregnant or With Child Application
(Doris House Application)

Transitional Housing Application

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A new tab will open and this page will redirect to Google

Single Application(Oglesby House Application)

Pregnant or With Child Application(Doris House Application)

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Here To
Quick Exit

Single Application
(Oglesby House Application)

Pregnant or With Child Application
(Doris House Application)