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Application
*Iowa residents only*
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General Information
Name
*
First
Last
Email
*
Date of Birth
*
Current Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Alternative Phone Number
Were you in foster care between ages 12-18?
*
Yes
No
Children
1. First Name
1. Last Name
1. Gender
Female
Female
Male
Non-Binary
Prefer Not to Say
1. Date of Birth
2. First Name
2. Last Name
2. Gender
Female
Female
Male
Non-Binary
Prefer Not to Say
2. Date of Birth
3. First Name
3. Last Name
3. Gender
Female
Female
Male
Non-Binary
Prefer Not to Say
3. Date of Birth
4. First Name
4. Last Name
4. Gender
Female
Female
Male
Non-Binary
Prefer Not to Say
4. Date of Birth
5. First Name
5. Last Name
5. Gender
Female
Female
Male
Non-Binary
Prefer Not to Say
5. Date of Birth
6. First Name
6. Last Name
6. Gender
Female
Female
Male
Non-Binary
Prefer Not to Say
6. Date of Birth
Sources of Income
1. Source of Income (Employer, FIP, Unemployment, SSI etc.)
1. Monthly Amount
2. Source of Income (Employer, FIP, Unemployment, SSI etc.)
2. Monthly Amount
3. Source of Income (Employer, FIP, Unemployment, SSI etc.)
3. Monthly Amount
4. Source of Income (Employer, FIP, Unemployment, SSI etc.)
4. Monthly Amount
5. Source of Income (Employer, FIP, Unemployment, SSI etc.)
5. 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)
*
Some High School
Graduated High School
HISET
Some College
Graduated College
Have you received or currently receive FIP?
*
Yes
No
How many months have you received or are currently using FIP?
*
Have you ever been in an abusive relationship (physical or emotional)?
*
No
Current
Past
Did you receive support services
*
Yes
No
Have you ever been in any legal trouble of any kind?
*
Yes
No
Were you on probation or parole?
*
Yes
No
What was the charge?
*
Have you ever received treatment for or been diagnosed with any mental health issue?
*
Current
Past
No
What treatment did you receive?
*
Have you ever been involved with the Department of Human Services due to a child protective issue?
*
No
Current
Past
What was the reason?
*
How long ago did this happen?
*
Less than 6 months ago
6 months to 1 year
Greater than 1 year
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
Probation/Parole Officer Phone
DHS Worker Name
DHS Worker Phone
Substance Abuse Counselor Name
Substance Abuse Counselor Phone
BHIS Provider Name
BHIS Provider Phone
Other Service
Other Name
Other Phone
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.
Submit
House of Hope is tried, tested, and proven with an 93% success rate.