Covid-19 Rental Assistance Program- Black Hawk County, Iowa residents only
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Date of Birth
Date Format: MM slash DD slash YYYY
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Alternative Phone Number
Were you in foster care between ages 12-18?
Child's Date of Birth
Sources of Income
Source of Income (Employer, FIP, Unemployment, SSI etc.)
Do you have a driver's license?
Do you own a car?
Do you have car insurance?
Highest level of education (GED, High School, College)
Have you received or currently receive FIP?
How much have you used?
Have you used illegal drugs?
How long since your last use?
Have you ever been in an abusive relationship (physical or emotional)?
Did you receive support services?
Have you ever been in any legal trouble of any kind?
Are you currently/have you been on probation or parole?
Have you ever received treatment for or been diagnosed with any mental health issue?
What treatment have you received?
Have you ever been involved with the Department of Human Services due to a child protective issue?
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
Substance Abuse Counselor
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.
This field is for validation purposes and should be left unchanged.
House of Hope is tried, tested, and proven with an 86% success rate.