Young Adult Residential Application

Do you have a resume?

YesNo
Where you involved in any sports teams, clubs, or activities in school?

YesNo
If so, what activities?
Do you have television shows you enjoy watching?
Did you grow up with pets or do you have a pet?
Is there a movie you really like?
Have you ever tried any of the following?
Do you like to draw?

YesNo
Tell us about a positive memory you have - recent or from long ago - in which you felt happy and/or loved *
Has someone close to you ever died? If so, can you tell us about him/her & what happened *

Here is what we believe in at The Faine House

Can you offer your thoughts on what the following means to you:
Inclusive
Accountability
Discipline
Kindness
Joy
Why do you think you need this program? *
What are your goals in this program? *
I agree that I have completed this application in it's entirety & in truth to the best oy knowledge. I understand that dishonesty can hinder my approval.

Clear

AUTHORIZATION TO RELEASE CONFIDENTIAL RECORDS

The Faine House
I (young adult name) blank hereby authorize the release of confidential information consisting of Psychiatric Records or Information, Psychiatric Medications, Drug/Alcohol Records or Information, HIV or AIDS Information, Medical Records or Information; Social History: Psychological Records or Information, Educational or School Records, Assessments, Service/Treatment Plans, All records to The Faine House, Inc.
Please Check One

Complete Records FileRAP Sheet OnlyMedical Records OnlyCase Management Files Only
From: Individual/Organization:
To: Individual/Organization:
Date of Birth

MonthDayYear
Date
For the purpose of assisting with The Faine House services:

I understand the information released by signing this form may be further disclosed by the recipient and is then no longer protected by the Federal code as required by 45 CFR 164.508 ( c )(2)(iii).

This consent or authorization for release of information shall be effective the date of signature and shall expire one (1) year from the date of signature or may be revoked at any time, provided I notify the program in writing to this effect. Revocation has no effect on action previously taken.
Young Adult Printed Name:
Signature

Clear
Today's Date

MonthDayYear
Date
If the young adult has difficulty reading or understanding this document, please print the name of the person who read this document or explained it to him/her:
Should be Empty:

YOUNG ADULT RESIDENTIAL APPLICATION