• 21573 Foothill Blvd, Suite 210, Hayward, CA 94541
  • (510) 733-6800,
  • info@hollysplaceinc.org
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    To the Applicant:

    Complete the above information and give this form to your social worker that can comment about your potential to succeed in the Transitional Housing Program. This form MUST be completed by your social worker.

    To the Social Worker completing this form:

    The person whose name appears above has applied for the Transitional Housing Program through Holly Place. The selection committee would appreciate you answering questions below in a specific and candid manner, noting in particular incidents that illustrate the applicant’s maturity, initiative, and readiness for Holly Place.

    PLEASE BE SURE TO INCLUDE THE TRANSITIONAL INDEPENDENT LIVING PLAN

    Explain comments by using complete sentences; avoid short responses such as “yes” or “no”. If your relationship with this applicant does not allow you to make an evaluation of any item, please indicate “N/A” or not applicable.

    Yearsmonths
    Check how you rate the applicant’s characteristics and motivation.
    Strongly agreeAgreeSomewhat agreeDisagree
    Strongly agreeAgreeSomewhat agreeDisagree
    Strongly agreeAgreeSomewhat agreeDisagree
    Strongly agreeAgreeSomewhat agreeDisagree
    Strongly agreeAgreeSomewhat agreeDisagree
    Strongly agreeAgreeSomewhat agreeDisagree

    In order to be considered for Holly Place, the following must be received: 1) Recommendation Form, 2) Symptom Checklist (see next page), 3) A copy of most recent court report and the Juris/Dispo report. 4) Copy of the Transitional Independent Living Plan

    Please forward these materials to: Holly Place
    Holly Place 21573 Foothill Blvd. Suite 210 Hayward, CA 94541