Program Application

Starfish Program Application

To be completed by the applicant*

Please answer all questions to the best of your ability. Use additional paper if necessary.

Applicant

name:____________________________________________

Address:__________________________________________________

_________________________________________________________

How long have you lived there?_____________________

Future address if planning to move:______________________________

__________________________________________________________

Daytime phone:__________________ Evening phone:____________

Email address:_______________________

May we contact you by phone: yes or no by email: yes or no

Or mail: yes or no Which is your preferred method of contact?_________________

Best time to contact you:_________________________________________________

Applicant Birthdate:________________ Number of Children:_____________

Ages of Children:__________________ Other dependents in your care:___________

Other adults in your household:___________________________________________

Monthly Income: Indicate gross or net

Amount:___________ Source:_______________

If you are currently employed:

Place of employment:___________________________________________

Job position/title:_______________________________________________

*Your employer will not be contacted without your permission

Do you have a current open OFP or legal proceedings?________________________________

How did you hear about the Starfish Program?________________________________________

_____________________________________________________________________________

Self-Assessment:

Please circle the number that best rates your self-sufficiency in each area:

Completely

Dependent

Completely

Self-Sufficient

1 2 3 4 5 6 7 8

Financial

* Am I able to provide myself and family

with the necessities we need (shelter, food,

health care?) Is there a gap between my

monthly income and expenses?

Do I need to build my skill in managing

my resources? 1 2 3 4 5 6 7 8

Emotional

*Am I free from emotional abuse? Do

I believe I can succeed in life? Have I

taken steps to stabilize my situation? Do I

have low self-esteem? 1 2 3 4 5 6 7 8

Intellectual

*Am I free to express myself at home?

Do I have a good 1 2 3 4 5 6 7 8

understanding complex situations and how to

effectively express myself?

Eductional:

Have I completed my education? Do I have 1 2 3 4 5 6 7 8

work experience? Do I want to enhance this?

Physical

*Am I free from physical abuse? Do I

determine when/how I have sex? Am I free to

move about as I please? Do I have the

necessities that I need? 1 2 3 4 5 6 7 8

*What do you feel are your greatest strengths (where are you the most self sufficient)?

*Who or what could help you achieve greater self-sufficiency in weaker areas?

Personal Goals and plan for participation

· Tell us about your short and long term plans for your life.

· What steps have you already taken toward meeting those goals?

· What is your reason for requesting to be in this program?

· At this time, how do you feel you would like to spend the money received should it be available?

· Are you willing to attend group consistently and meet regularly with a Mentor to improve your skills and self-sufficiency and commit to a solid growth plan?

· What are the things you would most like to change about yourself?

· Describe your support network – those in your life whom you trust and who trust you.

· Describe your readiness to do weekly homework and to take action to implement new tools, knowledge and resources into your life.

· Are you ready and willing to be personally challenged and held accountable? You must be sure you are ready! Old, self-defeating behaviors will be challenged strongly.

· What fears, if any, do you have about participating in the Starfish Program?

· Share any other information you would like us to know:

· What questions do you have about the program?

By signing this application I agree that the information provided in this application is true and factual.

__________________________________

____________________________

Applicant Date

*All information provided is private and confidential. The Starfish Program will not disclose any personal information without written consent.

Print and complete. Send completed application to

Starfish Program

215 North Benton Drive

Sauk Rapids, MN 56479