Transitions Program ApplicaitonIf you are a young adult between the ages of 17-24, please fill out this form and learn more about how we can help support and empower you. PERSONAL INFORMATION: Referral Agency * First Name Last Name Date MM DD YYYY Applicant Referred By: First Name Last Name Phone (###) ### #### Name * First Name Last Name "Street" Name and/or Preferred Name: First Name Last Name Phone (###) ### #### Email * Date of Birth * MM DD YYYY Age: * Preferred Gender: * Race/Ethnicity: If American Indian, please indicate which tribe: Social Security Number Are you a U.S. Veteran? * Yes No Do you have (or have you ever had) Medicaid or Health Insurance? Yes No I Don't Know If yes, what coverage? ( Insurance Company Name or Medicaid #) Last place you lived: Address 1 Address 2 City State/Province Zip/Postal Code Country IF YOU ARE UNDER 18 YEARS OLD: Who is your parent or legal gurdian? First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email MENTAL HEALTH: Have you ever been diagnosed with any of the following (check all that apply): ADD/ADHD Depression Anxiety PTSD Bi-Polar Schizophrenia Do you currently (within the last 6 months) have a mental health care doctor and/or counselor? Yes No I don't know Examples: Family & Child Services "FCS", Counseling & Recovery Services "CRS", ect. If yes, where do you go and who do you see? If no, would you be willing to see someone? Yes No I don't know Are you currently (within the last 6 months) taking any mental health medications? Yes No I don't know If no, do you feel you should be taking medications? Yes No I don't know If yes, please list your current medications: SUBSTANCE USE/ABUSE: Do you currently have substance abuse challenges? Yes No I don't know If yes, please check all the substance(s) you struggle with: Alcohol Marijuana Synthetic Marijuana (K2, ect) Methamphetamines Prescription Medication Hallucinogens Other Would you be willing to see someone to address this challenge? Yes No I don't know LEGAL HISTORY: Were you ever in DHS custody? Yes No I don't know Currently in DHS custody If yes, where and for how long? Were you ever in OJA/Detention Center? Yes No I don't know Currently in OJA Custody If yes, Why? If yes, are you currently on probation? Yes No I don't know If yes, who is your probation officer? Are you currently involved in any of the following? Adult Judicial System Adult Drug Court Adult Mental Health Court Do you currently owe money for court fees, fines, probation, ect? Yes No I don't know If yes, how much do you currently owe? $ EDUCATION: Name of Last School Attended: Check the box with the highest grade you have completed: 6th-8th Grade 9th Grade 10th Grade 11th Grade 12th Grade High School Diploma GED Some College MISCELLANEOUS: Do you NEED any of the following? (Check all that apply) Driver's License OK Photo ID Social Security Card Birth Certificate Health Care Provider Food Handler's Card Food Stamps Health Insurance "Yes I Can" Benefits SSI/SSDI TANF Other Do you HAVE any of the following>? ( Check all that apply) Driver's License OK Photo ID Social Security Card Birth Certificate Health Care Provider Food Handler's Card Food Stamps Health Insurance " Yes I Can" Benefits SSI/SSDI TANF Other Do you have reliable transportation? I ride Tulsa Transit (Bus) I have a car/with insurance I have a car/no insurance I walk I ride a bike I don't have access to transportation at all SOCIAL SKILLS: I can wake up on my own in the morning: Yes No I can keep my room clean and safe: Yes No I can be on time for appointments: Yes No I can get along with my case manager: Yes No I can get along with my teachers: Yes No I can get along with my boss: Yes No I can get along with my co-workers: Yes No I can get along with my peers: Yes No I can get along with my roommates: Yes No I can get along with the police: Yes No INDEPENDENT LIVING: I can Find a job: Yes No I can KEEP a job: Yes No I can budget my money: Yes No I can go to the store and buy groceries: Yes No I can cook for myself: Yes No I can use a bank: Yes No I can keep myself safe: Yes No I know what to do if I get sick: Yes No I can use Tulsa Transit: Yes No RISK FACTORS (Check all that apply to you): Risk Factors Runaway Isolation from family & friends Recent drastic changes in sleeping pattern Recent drastic changes in eating habits History of neglect Inappropriate sexual behaviors Perpetrator sexual abuse Victim of sexual abuse Victim of physical abuse Use/abuse of drugs Use/abuse of alcohol Attempted suicide Suicidal thoughts Hallucinations Repeated lying, stealing, or property damage Physical aggression towards others Intentionally hurts others Intentionally hurts animals Self-Abusive behavior Sets fires Involvement in criminal activity Difficulty maintaining employment Difficulty maintaining safe housing Chronic illness History of inpatient psychiatric hospitalizations RISK FACTORS ( Check all that apply to your family): Family Risk Factors: Chronic physical illness in family Family history of mental illness Family history of psychiatric hospitalizations Family history of substance abuse Parental incarceration History of domestic violence Poverty Young adult exposed to substance abuse EMPLOYMENT: Have you ever had a job? Yes No If yes, where have you worked before? Do you currently have a job? Yes No If yes, where are you working? If yes, what is your schedule? PLEASE TELL US.... What makes you WANT the Transitions Program? What are some of your specific goals you'd like to work on while staying in the program? Thank you!
