HOUSING APPLICATION
Prosper House at Klimo Square
Please take the time to read this application and complete it to the fullest extent possible. The information you
provide will assist us in determining the stability of your housing situation and your eligibility for our programs.
Today’s Date
Your Name
Current
Address
City/State
Phone Number
Your Birthdate
Who do you Contact when there is
an Emergency?
Their Name
Their Address
Their Phone #
Referral Source
Their Name
Their Address
Their Phone #
Any
children?
If so, how many?
What age is/are your
child/children?
Your Current Housing Situation:
Are you homeless right now?
How long have you been
homeless?
Are you staying at a
Shelter right now?
If so, which one?
Check those situations that pertain to you:
Served a legal eviction notice within 30 days
Did not pay utility bills
Did not pay last month’s rent
Doubled with family or friends
Building in bad condition
Overcrowded living situation
Threats of being kicked out/asked to move out
Living with a parent/relative
If so, who? ________________________
Last Known Address
Landlord’s Name
Landlord’s Phone #
Street Address
City, State and Zip Code
Monthly Rent Amount
Average Monthly Utility Bill(s) Amount
Have you ever applied for government subsidized housing?
Yes
If so, when and where?
We have to ask you about your HEALTH status
Have you ever been treated for a mental health diagnosis?
Have you ever been hospitalized for a mental health issue?
If so, please tell us when that happened and where you received
treatment. Thank you.
How many hospitalizations have you had within the last 5 years?
Please list date, hospital, and purpose for admittance.
Use more room if necessary.
Are you on medication(s)? If so, please state the dosage and
purpose of each
Use more room to tell us if necessary. Thank you.
Please check any that apply to you
Learning disability
A.D.D./ADHD diagnosis
Developmental disability
Social/Emotional disorder
Seizure disorder
Autism diagnosis
Visually impaired
Hearing impaired
Please indicate the support services currently being provided to
you
Occupational therapy
Speech/language therapy
Individual counseling
Group counseling/support group
Domestic Violence
Are you homeless due to domestic violence,
abuse or assault in the last 30 days?
Income History
Are you currently working?
Where?
If so, has a police report been
made?
No
Since when?
How many Hours/Week?
Pay per Hour
What is your estimated
monthly income? (Including
SSI/Disability)
Do you currently have any
outstanding fines and/or
monies owed?
Yes
No
If so, how much?
Support Network
Do you have relatives that live nearby?
Who plays an important role in your support
network?
(list as many names as applicable)
How frequent is you contact with your identified
support network?
(please be as specific as possible)
Why can’t you stay with family or friends?
Check Which One(s) Pertains to you
Lease Violation
Financial Hardship
Overcrowded
Abusive Relationship
Health Issues
Too unstable or unsafe
Strained relationship
Other, please explain:
Education
What is the highest level of education complete?
Yes
Did you graduate high school?
No
Year Graduated
High School Name
Beginning with the ninth grade, please list every high school applicant has attended
Did you have a GED?
Yes
No
Yes
No
Please explain your educational goals.
Have you ever attended college?
If so, please indicate the school and date of attendance
Arrest History
Have you ever been convicted of a crime?
Please list any past criminal activity including ALL misdemeanors and felonies.
Also include any current outstanding community service, court fines, etc.
This information will NOT disqualify you from entering a PAL Mission program.
A background check will be conducted.
Description of Offense
Date of Offense
Jail Time
Served?
Yes
No
If yes, how long?
Probation/Parole Officer Name
PO Phone #
Next Court Date
Outstanding Community Service or Court Fines – Please Give Amounts.
Use 2nd page if necessary for any additional offenses
Assessment (FOR APPLICANT TO COMPLETE)
Please rate yourself on the following characteristics using a scale of 5 to 1
(5 indicating that the characteristic describes me very well, 1 indicating that the characteristic does not describe me well)
Example:
Reliability
School
Job
Home/Leisure
3
n/a
4
Job
Home/Leisure
Additional Comments
General (I regularly am/have…)
School
Additional Comments
Reliability
Initiative
Motivation
Perseverance
Interpersonal (I get along with and can have productive relationships with…)
School
Job
Home/Leisure
What is your style of interaction?
Please list some of your strengths and challenges
Peers with
Disabilities
Peers without
Disabilities
Judgement/Decision-Making (I have the ability to…)
School
Job
Home/Leisure
Additional Comments
Job
Home/Leisure
What types of situations do you find stressful?
Do you have coping mechanisms that you use?
Home/Leisure
Explain some difficulties you find in organization
Make everyday
decisions using
good judgement
Act in an
emergency using
good judgement
Use people as
resources (ask for
help)
Emotional (I have the skills to…)
School
Cope with stress
Adjust well to new
situations
Separate my
problems from the
problems of others
Time Management/Organization (I am able to…)
School
Attend to a daily
schedule
Plan activities
Prioritize
Job
Keep track of
personal belongings
Assessment (FOR REFERENT TO COMPLETE)
Please rate yourself on the following characteristics using a scale of 1 to 5
(5 indicating that the characteristic describes the applicant very well, 1 indicating that the characteristic does not describe the applicant well)
Example:
Reliability
School
Job
Home/Leisure
3
n/a
4
Job
Home/Leisure
Additional Comments
General (The applicant regularly has…)
School
Additional Comments
Reliability
Initiative
Motivation
Perseverance
Interpersonal (The applicant can get along with and can have productive relationships with…)
School
Job
Home/Leisure
What is the applicant’s style of interaction?
Please list some strengths and challenges
Peers with
Disabilities
Peers without
Disabilities
Judgement/Decision-Making (The applicant has the ability to…)
School
Job
Home/Leisure
Additional Comments
Home/Leisure
What types of situations does the applicant
stressful?
Make everyday
decisions using
good judgement
Act in an
emergency using
good judgement
Use people as
resources (ask for
help)
Emotional (The applicant has the skills to…)
School
Job
Cope with stress
Adjust well to new
situations
Separate my
problems from the
problems of others
Time Management/Organization (The applicant is able to…)
School
Attend to a daily
schedule
Plan activities
Prioritize
Job
Home/Leisure
Explain some difficulties the applicant may have in
organization
Keep track of
personal belongings
Please read the following CAREFULLY, then sign and date below.
The information provided on the previous pages is accurate and honest to the best of my
knowledge. I am aware this is NOT a promise of placement, it is ONLY an application. I
understand a background check will be issued on my criminal activity (if any).
I understand placing false information anywhere on this application may disqualify me from PAL
Mission programs.
I also understand placing false information on this application is grounds for termination should
I be accepted into a PAL Mission program.
Applicant Signature
Date
PAL Mission Staff
Date
Admission Process
Applications are processed within 48 hours of submission; however, housing cannot be secured until
our office receives all items outlined below:
1. Complete application (make sure all medical information is CORRECT and up-to-date) – no fee required
2. Recent psychological and neurological evaluation (completed within the last 3 years)
3. Verification of income
4. Signed authorization of release of information, per PAL Mission request
Prosper House at Klimo Square is a service provided by P.A.L. Mission
1253 3rd St. SE Canton, OH 44707
330.453.9199
www.palmission.org
Preparation for Adult Living