THE LINK
TRANSITIONAL LIVING PROGRAM (TLP)
Participant’s Name:
Referring Case Manager:
Date:
TLP Applications will not be accepted without the following COMPLETED items:
Participant Information Sheet
TLP Youth Questionnaire
TLP Participation Agreement
SMART Goals
Shelter Verification/Homelessness Documentation
Case Manager Referral
Letter of Reference
Check Stubs (minimum of 3 most recent check stubs)
For Scattered-Site Housing Program Manager:
Date Application Received:
Interview Date:
The Link
1210 Glenwood Avenue
Phone: 612.871.0748
Minneapolis, MN 55405
Fax: 612.871.0755
Web site: www.thelinkmn.org
Housing Program applying for (only select one):
TLP
GRH (first 3 pages only)
Section 1: Participant Information
Participant’s Name:
(First)
Social Security Number:
-
(Middle)
-
Birthday:
Gender Identity:
Contact Number: (
(Last)
/
/
Age:
Ethnicity:
)
Alternative Number: (
)
Email:
Name of Shelter:
Shelter Ph Number: (
Date Entered:
)
Shelter Address:
Have you previously stayed in shelter before?
How long have you been homeless?
□ YES
□ NO
□ 0-3 mo
If yes, where?
□ 3-6 mo
□ 6-12 mo
□ More than 1 year
Are you currently on a wait list for housing (transitional, subsidized, public housing, etc…)?
If yes, where?
□ YES
□ NO
□ YES
Are you currently working with any other case managers or agencies/programs?
□ NO
If yes, please include agency name(s) and contact person(s)
1.
2.
3.
Section 2: Education
Do you have:
GED
HS Diploma
Vocational Training
Are you currently in high school, college, or working toward your GED?
□ YES
Some College
□ NO
If YES, Name of School:
Please provide your school schedule:
Monday
Tuesday
Wednesday
Highest grade completed?
What is your anticipated graduation date (month/year)?
Thursday
Last date of attendance?
Friday
Section 3: Legal Income
Are you currently employed? □ YES
□ NO
Number of hours/week
Name of Employer:
Employment Status:
Rate of Pay $
/hr
Location (city):
Full-time
Part-time
Seasonal
How long have you been employed there?
Temporary
Start Date:
□ YES
Are you currently receiving any benefits?
□ NO
(Benefits include; food stamps, MFIP, WIC, SSI, Unemployment, Medical Assistance, Child Support, GA, etc…)
What benefits do you receive?
Amount $
/Monthly
Amount $
/Monthly
Amount $
/Monthly
Section 4: Health Information
Are you a victim of domestic violence?
□ YES □ NO
If yes, when did the last episode occur?
Do you have medical insurance (Medical Assistance, Minnesota Care)?
□ YES
□ NO
□ Unsure
Do you have any special health care needs (such as; asthma, epilepsy, seizures, etc...)? □ YES □ NO □ Unsure
IF YES, what are they?
Do you have a physical/mental health diagnosis or a documented disability?
(Examples of a disability may include the following, but are not limited to):
Traumatic Brain Injury (TBI)
Mental Illness (bi-polar, depression, schizophrenia, etc…)
Developmental Disability (fetal alcohol syndrome, ADHD)
Post Traumatic Stress Disorder (PTSD)
□ YES
□ NO
HIV/AIDS
Chemical Abuse or Substance Abuse
Hearing Impaired or Vision Impaired
Physical or medical limitations
Have you ever hit your head or been hit on the head? □ YES □ NO
If YES, did you go to the ER?
□ YES
□ NO
Did you lose consciousness or were you dazed and confused? □ YES □ NO
Afterwards, did you experience any problems like memory, staying focused, headaches, etc...? □ YES
Have you had any significant illness? □ YES □ NO
Do you have a primary care doctor or a clinic?
□ Unsure
□ YES
□ NO
□ NO
□ Unsure
If YES, please provide the name of your doctor and/or clinic
Do you have a therapist or have you ever attended therapy?
□ YES
□ NO
If YES, when was your last appointment (month/year)
Are you current taking any medications?
□ YES □ NO If YES, please list them:
□ Unsure
Section 5: Parenting
Are you a parent?
□ YES
□ NO Are you pregnant or have a partner who is expecting?
Child(ren) Name
Age
□ YES
Date of Birth
□ NO
Sex
1.
2.
Are you enrolled in a parenting group or program? □ YES □ NO
Do you have childcare?
□ YES □ NO
Do you have a job counselor?
If YES, where?
If YES, where?
□ YES
□ NO
If YES, please provide the name & agency of your job counselor:
Is the other parent involved?
□ YES
□ NO
Do you receive child support?
□ YES
□ NO
Section 7: Potential Barriers to Housing
Please answer each question honestly. This will not impact your application approval; it is useful information
for housing staff to have in order to advocate on your behalf to landlords.
Have you ever rented before?
□ YES
□ NO
If YES, was your name on the lease?
Name of Property:
City:
Have you ever been evicted or asked to leave by your landlord?
□ YES
□ YES
□ NO
If YES, what was the reason?
Do you owe money to past landlords?
□ YES
□ NO
Have you paid any of it back?
□ YES
□ NO
How much do you still owe? $
Do you have an unlawful detainer?
□ YES
□ NO
Reason for UD?
If YES, how much? $
LEGAL HISTORY
Have you ever been convicted of a felony?
YES
Have you ever been convicted of a misdemeanor?
Are you currently on probation or parole?
Have you had court involvement and/or charges within the previous 24
months?
Do you have any warrants for your arrest?
Are you an adjudicated delinquent or have an EJJ sentence?
Have you ever used a different name from the name given in this application?
Do you have a Probation Officer?
□ YES
If YES, please provide P.O.’s Name and Number:
□ NO
If YES, what County?
NO
□ NO
TLP PARTICPANT QUESTIONAIRE
(To be completed by Youth)
Participant’s Name:
Please answer the following questions. Make sure your responses are COMPLETE and THOROUGH.
*PLEASE TYPE YOUR RESPONSE*
1. Please tell your story. Explain the circumstances that led you to becoming homeless:
2. In what ways do you see The Link’s TLP program helping you achieve self-sufficiency? If accepted, what steps
will you take to ensure that this happens?
TLP Participation Agreement
As part of your participation in The Link’s Transitional Living Program, you are required to sign a contract that
identifies the expectations of your participation. The terms of your contract include the following;
1. DEMONSTRATE RESPECT! I will demonstrate appropriate communication and respectful behavior when working with
The Link staff, apartment management, and the community. I will demonstrate maturity and accountability of my actions,
behaviors, and decisions.
Inappropriate behavior, offensive language, and/or disrespectfulness will not be tolerated and will be grounds for immediate
termination from TLP.
2. I will schedule and be available for weekly home visits/meetings with my Housing Case Manager.
Home visits are reserved for one-on-one time with your Housing Case Manager. You need to plan for an hour with no
distractions and no guests. You may not miss a scheduled home visit without expressed consent from your Housing Case
Manager. If you need to reschedule, it is your responsibility to contact your Housing Case Manager 24 hours in advance.
3. I will let my Housing Case Manager know immediately if my phone number changes.
4. I will follow the rules of my apartment lease or rental agreement and I will not break the laws of the community. If I
receive 1 or more lease infractions, I will attend mandatory tenant education training.
You AND your guests will abide the Drug Free Crime Free Addendum and will not participate and/or engage in any illegal
activities in your apartment. I will notify my case manger immediately if I receive any lease infractions or complaints from
my apartment management.
5. I will not let anyone live in my apartment who is not on my apartment lease or rental agreement.
You will not let anyone live or stay in your apartment that is not on your apartment lease or rental agreement. Aside from
your lease agreement, The Link’s expectation is that no extended stay guests are allowed.
6. I will not pay more than 30% of my adjusted income for rent as defined by HUD.
7. I will make a contribution to my TLP savings account by the 1st of every month. This money will be held for me and
returned to me when I have successfully completed the program.
8. I will give 30 day notice in writing to the Housing Program Manager if I decide to end my participation in TLP.
9. I will attend all mandatory TLP meetings as I am notified.
10. I will work at least 32 hours a week if I am not enrolled in school or work a minimum of 10-12 hours a week if I am
enrolled in school.
11. If I lose my job, I will be employed within one month. I will utilize employment services/resources if I am having trouble
finding employment.
You will be required to provide verification of your job search progress.
12. I will attend school regularly if I have not completed my GED or received my high school diploma.
You are expected to attend school regularly and to maintain good attendance.
13. If I have children or am pregnant, I will participate in a minimum of two hours per month of verifiable parenting activities.
14. I understand that I may lose my contribution funds if I have damaged my apartment, abandoned my apartment, or if I do
not successfully complete the TLP program. The money may be used to pay for damages or any unpaid rent. I may keep any
additional money.
15. I understand that failure to follow this contract may result in a sanction or complete termination from the TLP program.
16. If I am evicted or asked to leave by my apartment management, my participation on TLP will be terminated.
Participant’s Signature:
Date
Creating S.M.A.R.T Goals
PLEASE USE THE FOLLOWING WORKSHEET TO ASSIST YOU IN CREATING THREE S.M.A.R.T GOALS YOU WANT TO ACCOMPLISH WHILE
ON TLP.
S
ACTION
STEPS
►
S.M.A.R.T
GOAL #1
S.M.A.R.T
GOAL #2
S.M.A.R.T
GOAL #3
M
A
R
T
SPECIFIC:
MEASURABLE:
ATTAINABLE:
REALISTIC:
TIMELY:
WHAT DO YOU WANT TO
ACCOMPLISH? DEFINE YOUR
GOAL; ANSWER THE WHO,
WHAT, WHERE, & WHY.
HOW WILL YOU TRACK
YOUR PROGRESS?
IDENTIFY MILESTONES FOR
YOUR GOAL.
IS YOUR GOAL WITHIN
YOUR REACH? WHAT
ACTIONS WILL YOU TAKE
TO ACHIEVE YOUR GOAL?
ARE YOU WILLING TO
COMMITT? WHY DO YOU
WANT TO REACH THIS
GOAL?
WHEN WILL YOU REACH
THIS GOAL? ESTABLISH
A START DATE AND AN
END DATE FOR YOUR
GOAL.
SHELTER VERIFICATION
Participant’s Name:
The person named above is applying for The Link’s Transitional Living Program. The Link is required to verify that
the applicant meets the HUD definition of homeless prior to acceptance. Please complete the following
information. This form may be faxed, mailed, or hand delivered.
I verify that
has been staying in our Emergency Shelter
Participant’s Name
from
Shelter Name
to
Month/Day/Year
.
Month/Day/Year
**********************************************************************
Date Completed:
Name of Agency:
Address:
City/State/Zip Code:
Shelter Ph Number:
Fax Number:
Name of Person Verifying:
Title/Position:
Direct Ph. Number:
To be completed by The Link’s Housing Staff:
Verbal Verification
OR
Written Shelter Verification (attached)
Yes, this applicant was residing in the emergency shelter the night prior to moving into his/her rental
unit.
Start date of shelter stay:
End date of shelter stay:
Move in date to rental unit:
Name of Shelter Staff Contacted:
Verifying Staff Signature:
Title of verifying staff:
Date:
CASE MANAGER REFERRAL
The responses to this survey will be used to assess the youth’s maturity level and their
emotional/behavioral independence. The assessment data may be used to establish the degree of
supportive services needed and case plan objectives. Please base your rating on your observations of
the participant’s behavior.
Participant’s Name:
Referring Case Manager:
How long you have worked with this youth?
Rating Scale:
A rating score of one to four (1-4) may be selected to each index in the survey. Score values are as
follows:
1= Skills are rarely observed
2= Skills are evident in some settings, but performance is inadequate and inconsistent. Skill is still
dependent on prompts and guidance.
3= Skills demonstrated in most settings, evidence of some level of internalization of skill.
4= Skills are mastered at a high level of quality and demonstrated consistently in all settings.
Life Skill
1. Can develop a realistic plan
with appropriate steps identified to
achieve goals.
2. Can establish priorities
3. Is capable of obtaining basic
needs
4. Can develop and carry out a
personal plan for goal
achievement without supervision
5. Can anticipate, with limited
input from others, what
consequences might be
associated with different choices
6. Demonstrates follow-through
(goals, appointments,
dependability)
7. Has some ability to resolve
conflicts with others. Knows where
to get help if unable to resolve
interpersonal conflicts alone
8. Can identify personal strengths
and needs (with assistance if
necessary)
9. Demonstrates maturity and
responsibility
10. Can ask for help
4-Mastered
3- Evident
2- Sometimes
1- Rarely
Case Manager Referral For:
1. Please provide examples of how this youth has demonstrated maturity and responsibility.
2. How would you describe the youth’s character/personality? List some of their attributes?
3. Please contact a family member or supporting adult to answer the following question.
Name of family member/supporting adult:
Relationship:
Date Contacted:
Phone Number:
Please explain the youth’s relationship with his/her family and indicate the reasons why it is not possible
for the participant to live with his/her family.
4. Do you have any concerns or suggestions in working with this youth? Please describe any potential
challenges the youth may face while participating in Freeport’s housing programming?
5. What level of service is needed:
Intense
Moderate
Minimal
CONSENT TO RELEASE INFORMATION
I,
, authorize The Link to exchange verbal and written
(Participant’s Name)
information with the following:
Agency Release
Agency Name
Address
City
Phone: (
State
Zip
)
Contact person to release information to:
Name:
Title:
Relationship:
I understand that this information may include a summary of:
Phone consultations
Chemical Health Evaluation
Goals & Progress
Diagnostic Evaluations & Recommendations
Discharge & Treatment
Psychological Testing
Rental Needs & History
Medication History
The purpose for the disclosure for the above information is:
□ Facilitate involvement of significant others in services
□ Coordination of services with the above named provider(s)
□ Advocacy in finding safe and secure housing
Other:
I understand that I have legal rights and that confidential information about me or my family is protected by data
privacy laws. This authorization is effective for twelve months after the date it is signed. I understand that I may
revoke this authorization at any time by writing to the Program Director at The Link. Disclosure of information can
be verbal or in written reports.
Participant’s Printed Name
Date
Participant’s Signature
Date
The Link Staff
Date
Letter of Reference
(COMPLETED BY SUPPORTING ADULT OTHER THAN REFERRING CASE MANAGER)
Date
Supporting Adult:
Contact Info:
has applied to The Link’s Transitional Living Program (TLP). TLP
is a HUD funded program working with homeless youth in transition ages 16+.
The purpose of TLP is to give youth an opportunity to live independently as they transition into adulthood. Youth gain a
rental history while working with a case manager on necessary skills and goals that will help them be self-sufficient in the
future.
To be eligible for TLP, a youth must meet the following requirements:
1. Documented homeless according to HUD.
2. Must have verifiable legal income.
3. Complete The Link’s Self-Sufficiency Series (or an approved Life Skills curriculum)
4. Must be referred by a case manager.
Please provide us with the following information by fax so that we may process the participant’s application. We request
information regarding the following:
1. How long and in what capacity have you known the participant?
2. Please discuss the circumstances that have led this participant to become homeless and/or precariously housed.
3. Pease assess his/her ability to live-independently (including maturity, dependability, and follow-through).
4. Do you have any concerns, comments, or suggestions regarding services for this youth?
Attached is a consent form authorizing the release of this information. Please complete this letter and fax to:
The Link - 612.871.0755
, ATTN:
Program Manager
Thank you for your time and cooperation.