IPLL Youth Application

INDEPENDENT LIVING PLUS YOUTH APPLICATION

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Date *

Name *

First

Last

Date of Birth *

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Education

Have you graduated high school? *

If no, what grade are you currently in? *

What is your favorite subject? *

What do you enjoy most about school? *

How would you rate your performance in school? *

Above Average
Average
Below Average

How would you rate your attendance in school? *

Above Average
Average
Below Average

If you have graduated, what are your plans regarding continuing your education? *

WORK EXPERIENCE

Are you currently working? *

If yes, where? *

If no, what types of jobs are you most interested in? *

PLEASE RESPOND THE FOLLOWING STATEMENTS

I can manage my emotions and feelings. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I know what my goals are for the next 6 months. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I know what my goals are for the next 12 months. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I know what my goals are for the next 5 years. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I often yell to get my point across. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I get physically aggressive with others. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I use or have experimented with drugs and/or alcohol. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

others. to you

I know my medical and mental health diagnosis. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I am willing and able to take my prescribed medications on my own. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I understand how to care for my personal hygiene. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I am comfortable communicating my feelings with others. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I am sexually active. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I understand how to protect myself from sexually transmitted infections and pregnancy. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

What are 3 of your biggest achievements?

List 3 of your strengths.

List 3 things you hope to achieve in Independent Living Plus.

What are 3 areas you feel you could improve upon?

What 3 things do you feel are most important to know when living on your own?

Name three people you can count on for support?

References

Reference 1 *

First

Last

Reference 1 Email *

Reference 1 Phone Number

Reference 2 *

First

Last

Reference 2 Email *

Reference 2 Phone Number *

Reference 3

First

Last

Reference 3 Email

Reference 3 Phone Number

FINAL THOUGHTS

In your own words, what does Independent Living mean to you and what do you want to accomplish while in ILP?

Additional comments you feel would be helpful for our team to be aware of:

Signature

Clear Signature

By submitting this application, I understand that I am being considered for Whaley Children’s Center Independent Living Plus Program and that I will receive an interview with the team to discuss the program and answer any questions.

Documentation Upload *

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Through dynamic leadership and dedicated staff and volunteers, Whaley Children's Center will be a source of hope, care, and treatment to Michigan's abused, neglected, and at-risk children and families.

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Contact

Whaley Children's Center
1201 North Grand Traverse Street
Flint, MI 48503

Phone: (810) 234-3603

Hours

Mon: 9:00AM-5:00PM
Tue: 9:00AM-5:00PM
Wed: 9:00AM-5:00PM
Thu: 9:00AM-5:00PM
Fri: 9:00AM-5:00PM
Sat: Closed
Sun: Closed