Application - House of Hope

General Information

Name *

First

Last

Email *

Date of Birth *

Current Address *

Address Line 1

Address Line 2

City

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

1. Date of Birth

2. First Name

2. Last Name

2. Gender

2. Date of Birth

3. First Name

3. Last Name

3. Gender

3. Date of Birth

4. First Name

4. Last Name

4. Gender

4. Date of Birth

5. First Name

5. Last Name

5. Gender

5. Date of Birth

6. First Name

6. Last Name

6. Gender

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) *

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? *

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.