If you are 21 years or younger and in need of immediate help, call (316) 262-HOME or go to any QuikTrip, fire station or anywhere you see the Safe Place logo and ask an employee to call our Street Outreach staff.

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Get Started on the Path to Independence With BRIDGES!

We are glad you are interested in the Wichita Children’s Home BRIDGES Program. There are several steps for you to complete in order to be considered for admission to BRIDGES.

First, complete ALL sections of the application form. After your application is received and reviewed, you will be contacted by Street Outreach. Street Outreach will work with you to better understand your needs and refer you to:

Mental Health Assessment: You will need to schedule and complete a short mental health assessment to determine if you have any mental health needs or issues of which we should be aware.
Substance Abuse Assessment: You will need to schedule and complete a short substance abuse assessment to determine if you have any alcohol or drug use issues of which we should be aware.

If you are accepted into the program, there are a few more steps:

Health Checkup: You will need to schedule and complete a checkup with your own doctor to determine if you have any health issues of which we should be aware. If you do not have a medical doctor, your BRIDGES Case Manager can help you schedule this.
Personal Documents: You will need a copy of the following documents: Original birth certificate, Social Security card, driver’s license or Kansas identification card, high school diploma or GED, and medical card or insurance card. We can help you with this, too.

But it all starts with completing the application! You can complete and submit the form below or download the application and send via email as a PDF or print and mail to:

Jennifer Avery
BRIDGES Program Manager
Wichita Children’s Home
7271 E. 37th St. N.
Wichita, Kansas 67226

BRIDGES Program Youth Application

Name:

Date of Birth (MM/DD/YYYY):

Gender:

Race:

Ethnicity:

Referred By:

With whom are you currently living?

Current Address:

Current Phone:

Do you have any children or are you expecting a child?

If so, please list the ages or expected due date of your child/children:

Reason for applying for the BRIDGES Program:

Have you ever been, or are you currently in custody?

If so, please list case manager’s name and any information related to custody:

Mother’s Name:

Mother’s Phone:

Mother’s Address:

Father's Name:

Father's Phone:

Father's Address:

School History

Current School:

Grade:

Type of Diploma:

Graduation Date (MM/YYYY):

Honors and Awards:

What do you like best about school?

What do you like least about school?

If you are not attending school, what is the highest grade level completed – and what is your plan for completing your education?

What are your educational goals?

Work History

Are you currently employed?

If yes, where:

Employer's Phone Number:

Length of Employment:

Previous Employer:

Length of Employment:

Previous Employer:

Length of Employment:

Previous Employer:

Length of Employment:

What type of work do you want to do for a living?

Medical/Mental Health

Do you have a medical or mental health diagnosis?

If yes, please elaborate:

Have you received treatment?

If yes, please elaborate:

Are you currently receiving treatment?

If yes, please elaborate:

Have you ever been in therapy or counseling?

If yes, with who and for how long?

Have you ever tried to harm yourself or someone else?

If yes, please elaborate:

Do you take any medications?

If yes, what are the medications for?

Do you take the medication(s) as prescribed?

Have you ever been hospitalized?

If yes, what for and how long?

Family Doctor:

Phone:

Does your family have a history of medical problems?

If yes, please elaborate:

Drug/Alcohol Use

What is your drug and alcohol history?

What treatment have you received?

Did you successfully complete treatment?

How long have you been drug/alcohol free?

What did you learn from the treatment program?

Describe any past or current drug or alcohol problem(s):

Are you willing to start or continue treatment if accepted into the program?

If not, why?

Criminal Record

Do you have a criminal record?

If yes, what did you do that resulted in this record?

What is the current status of your record? (on parole, probation, etc.)

Do you have any outstanding tickets or court cases pending?

If yes, please elaborate:

Goals

Please write three goals you would like to accomplish in the next six months:

Goal 1:

Goal 2:

Goal 3:

Please write three goals you would like to accomplish in the next two years:

Goal 1:

Goal 2:

Goal 3:

Autobiography

Please write a brief history of your life and how you got to where you are today.

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7271 E. 37th St. N.
Wichita, KS 67226
(316) 684-6581

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