Family and Adult Application

You are applying for the Adult Housing Transitional Program. Hillcrest is an alcohol-free, drug-free and pet-free property. We offer stable housing, financial management, and life skills classes to those interested in learning how to become independent and on the pathway to secure stable housing. If you are under the age of 23 years old and are interested in our Young Adult Transitional Housing program, please apply here.

Basic Information
Full Name including middle*
First Middle Last
A social security number is necessary for us to verify and process your application. A staff member will contact you by phone to explain our interview process and you will be asked to provide your social security number and submit to a background check at that time. Thank you.
Applicant Date of Birth*
Applicant Marital Status*
Gender*
Required for in-house statistical and tracking only. Information is not used in any decision-making process.
Ethnicity*
Required for in-house statistical and tracking only. Information is not used in any decision-making process.
List any aliases or maiden names:
Please list other cities and states you have lived in:
Co-Applicant (spouse) Full Name
First Middle Last
Co-Applicant Date of Birth
Co-Applicant Marital Status
Current Housing
Phone Number*
Email*
Current Address*
How long have you been staying there?*
Have you been asked to leave your current situation?*
- Yes
- No
How long can you stay there?*
What kind of transportation do you have?*
- Car
- Bus
- Bicycle
- Rely on Others
Have you lived at Hillcrest before?*
- Yes
- No
Who referred you to Hillcrest?*
Employment
Are you currently working?*
- Yes
- No
Company Name*
Employment Start Date*
MM slash DD slash YYYY
Pay Rate*
Second Job, Company Name (if any)
Second Job, Employment Start Date
MM slash DD slash YYYY
Second Job, Pay Rate
Is your co-applicant working?
- Yes
- No
Co-Applicant Company
Co-Applicant Employment Start Date
MM slash DD slash YYYY
Co-Applicant Pay Rate
Military Service
Have you ever served in the military?*
- Yes
- No
What branch?
When? (Service Dates)
Occupancy
Occupant List (List all who will live with you, including yourself)*
Name Age Relationship School Gender (Optional)
Is anyone pregnant?*
- Yes
- No
If so, what is the due date?
MM slash DD slash YYYY
Debt
Is there an eviction judgment or pending eviction?*
- Eviction Judgment
- Pending Eviction
- No
How Many evictions do you have that are hindering you from securing stable housing?
List utility companies applicant owes money to and the amount.
Income
Income currently received from job, food stamps, TANF, DFS, SSI, etc.*
Source Amount
Please explain your situation:*
Medical
Have you ever been a victim of domestic violence?*
- Yes
- No
If so, when?
Do you or any of the family members living with you receive any medical or counseling services?*
- Yes
- No
Medical or Counseling Services Listing
Name Problem Medication
Do you use drugs or alcohol?*
- Yes
- No
Have you ever been in drug or alcohol rehab?*
- Yes
- No
If so, when?
Facility Name
Name of Substance abused
Legal
Have you ever been arrested?*
- Yes
- No
For what?
Did you receive a fine or sentence?
- Yes, a fine
- Yes, a sentence
- No
Have you been incarcerated?*
- Yes
- No
Incarceration Beginning and End Dates
Are you on probation?*
- Yes
- No
Name of caseworker and contact information
Are you on parole?*
- Yes
- No
Name of parole officer and contact information
All information I have provided on this form true and correct?*
- Yes
Comments
This field is for validation purposes and should be left unchanged.

Address:
6600 NW Tower Drive
Platte Woods, MO 64151

Mailing Address:
PO Box 681298, Riverside, MO 64168

Hours: M-F, 8am-5pm
Phone: (816)382-3422
Website: hillcrestplatte.org

Hillcrest Platte County

Helping Homeless Families Find Their Way Home

HPC is a 501(c)3.
Our Tax ID number is
32-0073248.

All contributions are eligible for a tax deduction.

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Name	Age	Relationship	School	Gender (Optional)

Source	Amount

Name	Problem	Medication

Family and Adult Application

Basic Information

Current Housing

Employment

Military Service

Occupancy

Debt

Income

Medical

Legal

Hillcrest Platte County