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Abeona and Halcyon (STRTP’s)
STAY Program (THP+NMD)
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STAY Program
Supporting Transitional Age Youth
Application Form
Name
Application Date:
MM slash DD slash YYYY
Birthdate
MM slash DD slash YYYY
SSN
Requested Date for Residency
MM slash DD slash YYYY
Present Address
Phone #
How long at this address?
Identification Number
Have you lived in Santa Cruz County before?
When was the last time?
For how long?
Emergency Contact Name
Relationship
Phone #
Do you have your original Birth Certificate?
Do you have your original Social Security Card?
I am or have been in
Foster care
Probation
Legal guardianship
Name of last social worker or probation officer
Email Address
Demographic Information
Gender
Male
Female
Other
Primary Language
English
Spanish
LGBTQ
Yes
No
Hispanic or Latino?
Yes
No
Physical Disability
Race (select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Pacific Islander or Native Hawaiian
White
Special Needs
Alcohol Abuse
Developmental Disability
Domestic Violence
Drug Abuse
HIV/AIDS
Mental Illness
Employment/Education Information
Are you currently employed?
Yes
No
If yes, part-time or full-time
If yes, Where?
Start date
MM slash DD slash YYYY
Are you currently enrolled in an educational program?
Yes
No
If yes, Where?
Start date
MM slash DD slash YYYY
Health and Medical Information
Physical Health:
Good
Fair
Poor
Please list all currently prescribed medications
Are you currently under the care of a medical provider?
Yes
No
If yes, what is the name of your provider?
What is the address and phone number of your provider?
Do you currently or have you in the past seen a psychiatrist?
Yes
No
If yes, what is the name of your provider?
What is the address and phone number of your provider?
Legal Information
Have you ever been arrested? (If yes, please answer below)
Yes
No
Date
MM slash DD slash YYYY
Offense
Briefly describe incident
Are you currently on probation?
Yes
No
Do you have any current charges pending?
Yes
No
If yes, what charges
Family and Social Support
What type of support do you have from outside resources?
Tell Us More
What are your current goals?
What do you hope to gain from placement at STAY?
What are some of your strengths?
What are some areas you are struggling with?
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