CLIENT INFORMATION Record #______

Legacy Hall

Florence Crittenton Services

Youth Application

1300 Blythe Blvd. Charlotte, NC 28203

Phone: (704) 372-4663 Fax (704) 384-3169

Please complete application and email to

Ashley Beatty, Independent Living Program Manager,

Name:

First M. Last Nickname

Address:

Street City State Zip Code

Telephone #:

HomeWork

County/State of Residence:
Age: / Date of Birth:
Social Security #: / Race:
Tribal Affiliation (if Native American):
Name and Number of DSS Social Worker:
Medicaid #:
Name and Address of Primary Care Doctor:
What was the date of your last physical?
Are you currently taking any medication? If so please list.
Please list any allergies:
Do you currently feel supported ? / Yes / No

If yes, by whom?:

Please describe your current living situation:

Siblings?: / Sisters / Brothers

Do you have a current visitation plan? If yes, please explain.

What is your highest level of education completed:
Are you currently enrolled in school? / Yes / No
If yes, what school do you attend?

What are your educational goals?

Are you currently employed? / Yes / No

If yes, where, what position, and how many hours per week?

Supervisor’s Name: / Telephone #:

Please describe your previous work experience:

Have you ever been arrested? / Yes / No

If yes, please list date of arrests and what you were arrested for:

Have you ever been or currently on probation/parole? / Yes / No

If yes, explain:

Have you ever seen a counselor, therapist, or psychiatrist? / Yes / No

If yes, where and when?

Have you completed the Casey Life Skills Assessment? / Yes / No
If yes, please list date that you last took it:
NARRATIVE SECTION

Please state why you would like to be admitted into Legacy Hall, an Independent Living Program at Florence Crittenton services?

Please state what you hope to gain from the Independent Living Program?

Please list three or more things that you like about yourself.

Please list three things about yourself that you feel need improvement.

What do you think you will do when you leave the program?

Please list any additional information that you feel is important.

Legacy Applicant: / Date:
Legacy Guardian: / Date:

F:\WPDOC\WPDOC\DROPBOX\Human Resource Folder\Forms\Intake Forms\PALS\Legacy Hall Client Application for Residence.doc ARB 12/1/10