House of Hope

General Information

Name*

First Last

Email*

Date of Birth*

Current Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Alternative Phone Number

Children

Child's Name	Gender	Child's Date of Birth

Sources of Income

Source of Income (Employer, FIP, Unemployment, SSI etc.)	Monthly Amount

Driving Information

Do you have a driver's license?*

Yes
No

Do you own a car?*

Yes
No

Do you have car insurance?*

Yes
No

Additional Information

Highest level of education (GED, High School, College)*

Have you received or currently receive FIP?*

Yes
No

How much have you used?*

Have you used illegal drugs?*

Yes
No

How long since your last use?*

Have you ever been in an abusive relationship (physical or emotional)?*

Yes
No

Did you receive support services?*

Yes
No

Have you ever been in any legal trouble of any kind?*

Yes
No

Are you currently/have you been on probation or parole?*

Yes
No

Have you ever received treatment for or been diagnosed with any mental health issue?*

Yes
No

What treatment have you received?*

Have you ever been involved with the Department of Human Services due to a child protective issue?*

Yes
No

When was your involvement and what was the reason for involvement?*

What situation(s) led to you being homeless?*

What are your goals, where do you want to be by the time you complete the House of Hope program?*

What steps have you taken to reach those goals?*

Services You Receive

Probation/Parole Officer

Name	Phone Number

DHS Worker

Name	Phone Number

Substance Abuse Counselor

Name	Phone Number

BHIS Provider

Name	Phone Number

Other

Service	Name	Phone Number

Agreements

If I am accepted into the House of Hope program I agree to the following:*

I agree to work or go to school full time.
I agree to abstain from all illegal substances.
I agree to follow guest curfew.
I agree to attend weekly case manager meetings and weekly group meetings.
I understand that applicants that agree to come into office and meet with the case manager once a month and call once a month, while on the waiting list will be moved to the top of the list. Please drop by the office on Wednesdays between 1pm - 4pm or Thursdays between 9am – 12pm. For the phone calls, you can call anytime and leave a message on any updates if no one answers.
I voluntarily allow release of information with the above listed services and/or individuals solely for the purposes of determining eligibility for admission to the House of Hope. I understand this information will not be shared with anyone else by either party without my consent.
I may revoke this consent to release information at any time. I understand that this release and application are valid for one year from the date the application is received.
I verify that the information I have shared on this form is true, accurate and complete. I understand that any untrue, inaccurate or incomplete information may result in my application to House of Hope being denied.

Phone

This field is for validation purposes and should be left unchanged.

Application