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Birth Date


Phone Number





Are you under the care of any of the following?
Check all that apply.

Alcohol History

Drug History

Have you ever been involved in any recovery programs?
Did you complete the program?
Check all that apply.
Check all that Legal matters that apply.

How much time have you spent? (Years, Months or Days) 

Officer's Name

Phone Number


Caseworker's Name

Phone Number


Please list all convictions, the Year and Time Served. 



What have you learned about yourself in the last year?

What kind of groups, clubs, or activities have you been involved with?

What kinds of problems are homeless youth facing?

What kinds of problems are you facing?

What kinds of things have you done to help yourself in the past month?

Are you ready to change your life? Why?

If you could, what would you change about yourself?

List 3 behaviors you would like to change

Is there anything else you need help with?

Are you willing to sacrifice some of your freedom in order to be successful in this program?


Did you attend church or participate in a religious activity as a child?

Do you currently affiliate yourself with a religion?

Do you think you can succeed with your life goals in a Christian, faith-based program?

What part does God play in your life?


Was your mother using drugs/alcohol during her pregnancy with you?

Who raised you as a child?

Was either of your parents missing during your childhood?

Describe the best relationship (family, friend, romantic) you have ever experienced.

Describe the best day of your life.

Describe what does an average day look like for you.

What area (City and State) did you grow up in?


Do you have any siblings?
Did your parents experience divorce?
Were you ever in foster care?
Do you know the names of your birth mother and father?
Are you currently speaking to your parents(s) or guardian(s)

What family members do you look up to the most? Why?

Do you have any friends that you can count on? What are their names?

Are you currently involved in a romantic relationship? What is their name?

Do you have any children of your own? What are their names and ages? Where is your child currently living? Was CPS ever been involved?


What do you hope to accomplish if you become a member of one of our houses?

How do you define success? What would your life look like if you were successful?

What was the most successful time in your life?

How do you typically handle conflict?


If a resident confronts you about something, he owns that went missing, and they believe you stole it, how would you handle that conflict?

If a Resident Advocate (RA) asks you to redo a chore that they observed was not completed, but you believe it was completed, how would you handle that situation?

If you came home from a rough day at work and a fellow resident says something sarcastic to you that really get under your skin, how would you handle that conflict?

If the House Manager confronts you about a behavior you display that is negatively affecting the house, how would you handle that?


In the Bible, the Word of God – inspired and authoritative In one God who exists eternally in three persons; Father, Son and Holy Spirit. In the Deity of our Lord Jesus Christ, in His virgin birth, in His sinless life, in His miracles, in His substitutionary and atoning death through His shed blood, in His bodily resurrection, in His ascension to the right hand of the Father and in His future personal return to rule in power and glory. We believe that for the salvation of lost and sinful people, regeneration by the Holy Spirit is absolutely essential and that this salvation is received through faith in Jesus Christ as Savior and Lord and not as a result of good works. In the complete forgiveness and eternal salvation of the true believer. In the empowering ministry of the Holy Spirit, who lives in Christians, thereby enabling each to live a godly life In the bodily resurrection, judgement and eternal conscious existence of both the saved and the lost. In the spiritual unity of believers in our Lord Jesus Christ. I have read and understand that Transitional Youth is faith based/Christ centered. 


The information contained in this document will be treated with the utmost confidentiality and respect. Transitional Youth has strict criteria for the treatment and storage of confidential documents. 

Release to Do Reference Checks and Criminal Records Check I authorized my references, present and past employers listed in this application, to give Transitional Youth any information, including opinions, they may have regarding my character and fitness to be employed or volunteer with Transitional Youth. This release and authorization acknowledge that Transitional Youth may now, at any time while employed or as a volunteer, obtain and use a “consumer report” about me, which may include verification of my education, previous employment/work history, driving record, and criminal record that may be in the files of the federal, state, or local criminal justice agency in any state. A photocopy or telephonic facsimile (FAX) of the Authorization and Consent for Release of Information shall be valid as the original. The results of this verification process will be used to determine employment or volunteer eligibility. All results will be kept confidential. The information obtained will not be provided to any parties other than to Transitional Youth personnel, and their professional advisors and consultants if deemed appropriate in either’s sole discretion. I authorize the Oregon State Police Department, or any other company doing business with Transitional Youth that provides background information, to release any information that pertains to any record of convictions in its file or in any criminal file maintained on me, whether local, state, or national, and to disclose orally and in writing the results of this verification process to authorized representatives. I do hereby agree to forever release and discharge Transitional Youth, its interviewers, to the full extent permitted by law, from any claims, damages, losses, liabilities, cost and expenses, or any other charges or complaints arising from the retrieving and reporting information. In the event that information from the consumer reports is utilized in whole or in part in making an adverse decision with regard to my application, before making the adverse decision, Transitional Youth will provide me with a copy of the report and a description in writing of my rights under the law. I hereby authorize Transitional Youth to obtain a consumer report on me. I also certify that all the information that I provided in this application is true and complete. I understand that any false or misleading information may prevent me fro volunteering with Transitional Youth/Braking Cycles. 

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