F2B1

*

Transitional Application

Today's Date*
PERSONAL INFORMATION

Marital Status*
Date of Birth*
Which Transitional Support Program Options are you applying for?* Aftercare (extension in current location for up to 3 months only available for current Refuge for Women residents) Transitional Living (Refuge for Women-managed housing/available at limited locations) Transitional Care Program (does not include housing)
If you selected Transitional Living, which location are you requesting? (We will try to accommodate your requested location based on availability)
Why did you select the option you did? Why do you want to enter the Refuge for Women Transitional Support Program?*
Please indicate your Refuge for Women program location (current location):*
If Non-Refuge for Women program, please provide the name and location of other program (this is required to be considered for acceptance if non-RFW resident):
Please list the dates you attended this program?*
Phone number where you can be reached (Non-Refuge only)
Email address where you can be reached (Non-Refuge only)
What recovery meetings do you attend regularly?*
Which church fellowship are you a part of?*
Do you have underage children?*
If you have underage children, what are your plans for their care if you are accepted into the Transitional Support Program? Please include custody arrangements.
What are your hopes for contact with family members while in the program?*
Please list three goals you want to accomplish while in the Transitional Support Program:*
EDUCATION AND WORK

What are your plans for work while in Transitional Support Program?*
What are your expected expenses during your time in Transitional Support Program?*
Please list your savings plan for your time in Transitional Support in timeline format (for example, at month 1 I will have saved___; at month 6 I will have saved___; etc.):*
What are you plans for education (if needed) in Transitional Support Program?*
MEDICAL INFORMATION

List all medications you are currently taking, dosage, and reason for taking:*
Please list any medical procedures you are anticipating during your time in Transitional Support Program (include both medical and dental):*
What are your plans for transportation? (Please note that rides from others will need approval from RFW)*
Do you understand that transportation needs in the Transitional Support Program are your responsibility? This includes medical appointments, therapy or counseling sessions, refilling medications, and to and from work or school.*
RECOMMENDATION AND ATTESTATION

Please list name and contact information for program leader who will write your letter of recommendation (required for non-RFW applicants):
The program guidelines will be provided to you prior to approval to enter to the program for your review and signature of agreement to abide by the program expectations.