Dear Applicant, If you are interested in THP+FC or THP+ housing please complete
the attached referral form and submit it us. Your referral will
be reviewed by the intake coordinator to identify if our program
will best meet your needs. Please contact us with any questions
you may have. Please note that completing this referral form does
not guarantee placement with Monarch THPP-FC or THP.
General Information
Program Applying for:
THP+
THP+FC
Name:
DOB:
Age:
Street
Address:
City:
State:
Zip:
SSN:
Home
Phone:
Cell
Phone:
Email
Address:
Referral
Source:
Are you
currently pregnant OR soon to be fathering a new child that you
will have custody of? Yes
No
Do you have children? Yes
No
If
yes, how many are living with you?
Are you currently in foster care or in an out
placement? Yes
No
If yes, what is your current placement? Group
Home
THP
Foster Home
SILP
Other
If no, what was your emancipation date:
Are you currently on probation? Yes
No
Were you previously on probation? Yes
No
Name of current/last social
worker:
Phone:
County:
Name of current/last
probation officer:
Phone:
County:
Education & Employment
Have you obtained any of the following? Certificate
of Completion
GED
High School Diploma
What best describes your current education status?
Never attended high school
Dropped out of high school and not currently attending school
Attending high school or GED program
Received certificate of completion and not currently attending school
Received high school diploma/GED and not currently attending school
Attending vocational training school
Attending community college
Attending four year university
Obtained associates degree (AA) or technical degree and not currently
attending school
Obtained bachelor's degree
Other - Specify:
If not enrolled in school, are you interested
in enrolling in school? Yes
No
Do you currently or did you previously have an
IEP? Yes
No
If enrolled in school, what school?
What best describes your current employment status?
Employed Part-Time
Employed Full-Time
Current Employer:
Position:
Not employed but actively seeking employment
Not employed and not actively seeking employment
If employed, what is your total income from employment
in the last month?
What is your primary source
of income?
Total monthly income from all
sources:
Wellness
Which of the following describes your general
emotional state? (More than one is OK)
Stable
Happy
Sad
Confused
A little depressed
Very depressed
Unstable
None of them
Have you ever had a mental health diagnosis?
Yes
No
Unknown
If yes, please specify:
Do you currently have a therapist? Yes
No
If yes, Name:
Phone:
We will not contact your therapist without
your permission.
Do you currently have a psychiatrist? Yes
No
If yes, Name:
Phone:
We will not contact your psychiatrist without
your permission.
Do you receive SSI/SSDI: Yes
No
If yes, what do you receive SSI/SSDI for?
Please list all prescription medication that
you take.
Medication Name Reason / Purpose Length
Physical Health
Mental Health
Other.
Please explain why
Have you been hospitalized in the last two (2)
years? Yes
No
Please explain why
Have you ever been in a treatment program for
substance abuse? Yes
No
If yes, name of program and length of stay
Do you have health insurance? Yes
No
MediCal
If insured MediCal #
MediCal Issue Date:
Other Health Insurance
Specify Other Insurer
Other Insurance ID#
Family or Kin Support
Is your kinship/family network: Very Supportive
Supportive
Not supportive
No contact
Is your social network: Very Supportive
Supportive
Not supportive
No contact
Criminal History
Have you been convicted of a violent felony as
an adult? Yes
No
Please explain
Location & Housing
Do you feel you have safe and stable housing?
Yes
No
If no, do you need emergency shelter? Yes
No
What best describes your current living situation?
Foster care or out of home placement >>Specify
Renting own or shared housing (paying rent)
Living with relative or other person in stable housing (rent free)
College Dorm
THP-Plus program >>Specify
Other supportive transitional housing program >> Specify
Motel or Hotel
Other unstable housing situation (couch surfing with relatives,
friends, or other people)
Emergency shelter, homeless or other unstable housing (street, car,
etc.)
Institutionalized (just exited hospital, jail, mental health facility
with no place to go) >> Specify
Do you require reasonable housing accommodation
due to a disability? Yes
No
If yes, please complete a reasonable accommodation
request form.
If you were to be placed into one of our housing
programs, what type of housing do you think you would prefer?
Please rank from first choice to last choice:
Individual or shared apartment at scattered sites
Host home with a permanent adult
Community/single?site housing (also known as staffed housing)
If interested in host housing, do you have a permanent
adult that you can live with? Yes
No
Unknown
N/A
Name
Address
Phone
Assistance
What can we help you with?
Housing
Employment
Education
Other >> Specify:
What are your educational goals and how do you
think our program could help you achieve them?
How would you describe yourself?
What are your greatest strengths that would help
you be successful in our program?
What are some things that are getting in the way
of your goals and/or challenges?
Have you ever been housed by a THP+ program or
transitional housing program? Yes
No
If yes, which one(s) and for how long?
Agency(ies):
# of Months:
Have you applied to other housing programs? Yes
No
If yes, which program(s)?
Please review your answers before submitting,
thank you.
