Rental Application for Blossom Place

General Information

Name:	Application Date:

Address	:

City:	State:	Zip Code:

Phone:	E-mail:

Last 4 Social Security Number:	Birth date:

Did you age-out of foster care:	Date you aged-out:

Social worker’s name:	Phone:

Do you have a mentor, CASA or other supportive adult relationship?

Name:	Contact info:

Do you have a CA driver’s license?

Do you have a car?	Insurance Co Name:

Make:	Model:	Color:	Plate #:

Important Stuff

Work

Are you currently employed:	Where:

How long on the job:	How many hours per week:

School

Did you graduate from high school:	Complete GED:

Are you currently in school:	Where:

Do you plan to go back to school:	When:

What are your educational goals:

Finances

What is your primary source of income:

Do you have a checking account:	Balance:

Do you have a savings account:	Balance:

Legal Stuff

Are you or have you ever been on Probation?

Probation/Parole Officer:	Phone:

Please explain the nature of the incident?

Medical Info

Please list any medical conditions past or present:

Please list any mental health issues past or present:

What prescribed medications are you currently taking:

Have you ever been hospitalized? If so, please explain:

A Little about You

List three things you like about yourself:

1.

2.

3.

List three things about yourself that you feel need improvement/attention:

1.

2.

3.

Goals

What are your plans for the future?

Social Skills

On a scale of 1-5 (1=Poor, 5=Best), how would you rate yourself at the following:

Hygiene:	Wake up on your own:	Communicating clearly:

Being on time:	Getting along with others:

Independent Living Skills

On a scale of 1-5 (1=Poor, 5=Best), how would you rate your ability to:

Purchase Food:	Budget money:	Laundry:

Prepare well balanced meals:	Purchase clothing:	Household chores:

Take care of others:	Use banks:	Find jobs:

Hold jobs:	Use public transportation:

Use hospital:	Use Library:	Knowledge of colleges:

Use computer:	Use telephone:

Problem Solving

How do you deal with your anger?

How do you deal with peer pressure?

How do you deal with authority figures?

What do you do with your free time?

What do you do when you are alone?

Why Blossom?

Why do you think Blossom would be a good place for you to live?

References

By listing names and phone numbers below, you are indicating that you agree to allow us to contact anyone listed as a reference to aid in our decision to accept you into Blossom Place. Please do not list family members or friends. List persons from other programs you have been in, counselors, school personnel, employers, etc.

Name:	Phone:	Relationship:

Name:	Phone:	Relationship:

Emergency Contact

Name:	Relationship:

Phone:

By submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge, I agree to allow my references to be checked and I agree to the application process.

Name:

Signature:

Date:

530-613-2822	info@BlossomPlace.org