Pillars

Pillars Application for Services

Application for services

• Date*
• Name*
  First Last
• Date of Birth*
• Current Address*
• Phone Number
• Alternate Phone Number
• Do you have children?*
• Were you in foster care during the ages of 14-17?*
• If yes, when and how long?
• Did you age out of foster care?*
• Do you receive any after care services or benefits?*
• Do you have a valid driver's license?*
• Do you own a car?*
• Do you have car insurance?*
• Source of income and monthly amount?*
• What is your highest level of education (GED, high school, college)?*
• Have you used illegal drugs? If yes, when was the last time you used?*
• Have you ever been in an abusive relationship? If yes, did you receive support services?*
• Have you ever been in legal trouble of any kind? If yes, please explain:*
• Are you on parole or probation?*
• Have you been diagnosed with any mental illness? If yes, did you receive treatment?*
• Have you ever received in home services? If yes, please explain:*
• What led you to the Pillars program?*
• What goals do you hope to achieve in the Pillars program?*
• What steps have you taken to reach those goals?*
• Probation/Parole Officer name and number:
• Aftercare Worker name and number:
• Substance Abuse Counselor name and number:
• Academic Advisor/Teacher name and number:
• Other service provider name and number:
• If accepted into the Pillars program, I agree to work or go to school 80 hours/month, abstain from all illegal substances, respect myself, my environment, and others living and working at the house, follow guest curfew and rules, and attend weekly case manager meetings and life skills classes. Please initial:*
• I voluntarily allow release of information with the above listed services and/or individuals soley for the purposes of determining eligibility for admission to the Pillars program. I understand this information will not be shared with anyone else 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 being denied. Please enter your electronic signature and date in the box:*

Growing up is hard.

Transitioning out of foster care is a significant challenge—it requires you to grow up. Fast. We can help make that transition a little easier, and a little less scary, by helping figure out how to live independently.

Join the family.

By joining the Pillars program and House of Hope family, you’ll receive:

• A permanent home for two years
• Encouragement and support to achieve independence
• Individualized case management assistance and support services.
• Life skills classes, mentoring, and tutoring services