PARENTS’ FOUNDATION FOR TRANSITIONAL LIVING, INC. 100 BROADWAY, NEW HAVEN, CT 06511 TO BE CONSIDERED FOR ADMISSION TO THE RESIDENTIAL LIVING CENTER Applicant's Information Name* First Last SS#* Date of Birth* MM slash DD slash YYYY Marital Status* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Referrer's InformationReferrer's Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Referrer's Title* Organization* Referrer's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Referrer's Phone*Referrer's Email* Primary reasons for this referral for need to live in a supervised, mental health group living situation.* Support psychiatric stability Support medication compliance Live safely in community Develop independent living skills Live in an active, social setting with behavioral health support Pursue productive activity daily Transfer to a residential living setting in an urban area Support / advocacy for health care Gain independent living skills to transition to next level of more independent living setting Other Please specify which areas of independant living skills apply (ex self-care, hygiene, room maintenance, cooking, managing money, etc.Please provide more information around your answer, "Other" To be completed by referrer1. Is the applicant able to be responsible for own behavior and safety in an urban environment? 2. Is the applicant able to fully care for personal hygiene needs with moderate level of verbal prompts? 3. Is the applicant able to follow direction to complete laundry, room cleaning? 4. Is the applicant able to comply with medication regimen? 5. Is the applicant able to attend group activities? 6. Is the applicant able to understand the consequences of using alcohol and or illegal drugs while taking prescribed medication? 7. Is the applicant able to refrain from using alcohol and illicit drugs? 8. Is the applicant able to confine smoking to designated spaces? 9. Is the applicant able to respond to fire warnings? 10. Is the applicant able to abide by a curfew? 11. What is the applicant’s current living arrangement? 12. Does the applicant have a conservator or legal guardian? 13. What is the primary goal while at a residential setting? 14. What is the anticipated length of stay in a residential setting? 15. If dismissed form this residence, where would this applicant go? 16. Has the plan in #15 been coordinated and agreed to by the parties involved? To be completed by Applicant1. Do you have children? 2. Who are your social supports? 3. Have you been convicted of a misdemeanor? 4. Have you been convicted of a crime? 5. Do you use illegal drugs? 6. Do you drink alcohol? 7. Are you willing to abide by this organization’s rules and policies? 8. Do you understand that if you bring drugs, alcohol, or arms to this building you will be dismissed immediately? 9. If you were dismissed, were would you go? 10. Has the response noted in #9 been coordinated and agreed upon by the parties involved? 11. Do you, the applicant, agree to come to our facility for an interview and tour?* Yes No Submit
