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

Were you in foster care between ages 12-18?*

Yes
No

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.

Comments

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Application