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Intake Application

For admission or referral either complete the on-line application below or print out and complete the pdf application.

Download & Print PDF Application

Date of Referral

Program Referred To (check 1):

Supported Independent Living Program - SILP

Next Step Program

Second Chance Home

Referring Agency

Contact Person

Telephone #

Please state the current reason for referral including anticipated date of transition into the program

Was the youth homeless at the time of intake?

Yes

No

If not homeless, was there a risk of homelessness if not accepted to the program?

Yes

No

Youth's Name

DOB/Age

Ethnicity

Is the youth affiliated with a nationally recognized tribe?

Yes

No

If yes, Tribe Name

Current Address

Address

City

State

Postal Code

Country

Country of Origin

County Worker

Child's Name (1)

Date of Birth (child 1)

Child's Name (2)

Date of Birth (child 2)

Expected date of delivery

Parent/Guardian Name

Parent Address

Address

City

State

Postal Code

Country

Parent Phone #

Any visitation requirements (parents, siblings, etc.)

Yes

No

If yes, explain

Adult Resource (if applicable)

Adult Resource Address

Address

City

State

Postal Code

Country

Adult Resource Phone #

If applicable, name of your child(ren)'s father

Does your child visit with his or her father?

Yes

No

If yes, what is the arrangement?

Additional family supports for your child (grandparents, godparents, aunts/uncles, etc.)

Reason for Placement

Abuse/Neglect

PINS

JD

Voluntary

Permanency Plan Goal (PPG)

Return to Parent

APPLA

Adoption

Case Initiation Date (CID)

Are you currently enrolled in school or an educational program (this includes a GED program)?

Yes

No

If yes, Name and Address of School

Current Grade Level

Anticipated Date of Graduation

Do you have an IEP?

Yes

No

Date of Last Evaluation

Highest Grade Completed

7

8

9

10

11

12

Some College

Some Vocational

Name and Address of Last School Attended

Do you have a desire to continue your education?

Yes

No

If yes, what program would you be interested in?

Are you employed?

Yes

No

If yes

Part-time

Full-time

How many hours

Length of Employment

Employer Name

Is your child in formal daycare?

Yes

No

If yes, name of provider

Daycare Address

Address

City

State

Postal Code

Country

Daycare Phone

Hours of Daycare

Is transportaion provided?

Yes

No

Is this daycare paid by ECDSS?

Yes

No

If your child is not in daycare, are you interested in registering your child for daycare?

Yes

No

Who watches your child when you are working/going to school?

In the event of an emergency, do you have someone to watch your child?

Yes

No

If yes, name of person/people you can rely on

Medicaid Number

Youth's Physician

Youth's Physician Address

Address

City

State

Postal Code

Country

Youth's Physician Telephone

Child's Pediatrician

Child's Pediatrician Address

Address

City

State

Postal Code

Country

Child's Pediatrician Phone

Do you or your child(ren) have any medical conditions or illnesses?

Yes

No

If yes, explain

Do you or your child(ren) have any physical disabilities or impairments?

Yes

No

If yes, explain

Do you or your child(ren) take any prescribed medication?

Yes

No

If yes, explain

Do you or your child(ren) have any allergies?

Yes

No

If yes, explain

Do you or your child(ren) have unmet healthcare needs?

Yes

No

If yes, explain

Do you smoke cigarettes?

Yes

No

Do you use drugs and/or alcohol?

Yes

No

Are you currently enrolled in counseling?

Yes

No

If yes, name and address of counselor

How often do you attend counseling?

How do you currently get to counseling?

If you are not currently enrolled in counseling, have you ever been in counseling?

Yes

No

If yes, where did you attend?

When did you stop treatment?

Why did you stop treatment?

Are you interested in going back to counseling?

Yes

No

Do you currently have a mental health diagnosis?

Yes

No

If yes, what is your diagnosis?

If no, have you ever had a diagnosis?

Are you currently on medication for mental health needs (i.e. depression, anxiety, ADHD)?

Yes

No

If yes, what medication are you prescribed (name and dose)?

Who prescribes your medication (name of physician or clinic)?

Are you independent in taking your medication?

If you are not currently on medication, have you ever been on medication for mental health needs?

Yes

No

If yes, what medication(s) were you on?

When did you stop taking your medication?

Why did you stop taking your medication?

Are you interested in getting back on your medication?

Yes

No

Are you currently or have you ever been in drug and/or alcohol treatment?

Yes

No

If yes, what treatment program did you attend?

What did you receive treatment for?

If you have been discharged from treatment was it successful?

Yes

No

If you are not currently in treatment, do you feel that you need treatment?

Yes

No

Are you linked with any Health Home or in-home services?

Yes

No

If yes, what agency are you linked with (name and contact info)?

Have you ever been involved with Child Protective Services for your own child?

Yes

No

If yes, explain

Have you ever been involved with criminal court?

Yes

No

Have you ever been involved with criminal court?

Have you ever been convicted of a crime?

Yes

No

If yes, what offense:

Provide details

Have youever been in juvenile detention/non-secure detention?

Yes

No

If yes, provide details

Are you currently or have you ever been placed on PINS?

Yes

No

If yes, explain

Are there any orders of protection to be aware of?

Yes

No

If yes, please provide details

Have you ever been suspended from school and/or discharged from a program for fighting?

Yes

No

If yes, explain

Individual and/or Family Strengths

Interests and Activities

Goals

Reason you are interested in Homespace SILP/Second Chance Home/Next Step

If you are applying for the Supervised Independent Living Program (SILP), please answer the questions below. If you are applying for Second Chance Home or the Next Step Program, you have completed the application - thank you!

I prepare my own meals (select the statement that best describes yourself).

Always

Sometimes

Never

I prepare and keep a monthly budget.

Always

Sometimes

Never

I get myself to and from appointments on my own.

Always

Sometimes

Never

I am comfortable making appointments for myself.

Always

Sometimes

Never

I can resolve conflict with little help from adults.

Always

Sometimes

Never

I keep my living space neat and clean.

Always

Sometimes

Never

I am able to remember important appointments for myself and/or my child.

Always

Sometimes

Never

Please list items you already own and/or plan to purchase before moving into your apartment?

Please list any IL goals you have for yourself over the next 12-months

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Homespace

1030 Ellicott Street
Buffalo, NY 14209
716-881-4600

Second Chance

1171 Michigan Street
Buffalo, NY 14209
716-881-4600

Administrative Office

135 Delaware Avenue, Suite 210
Buffalo, NY 14202
716-881-4600

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