Application for Hope House Guest

Application for Hope House Guest 

Demographic Information

Full Name: Client first nameClient middle nameClient last name DOB: Client birthdate

Address: Client AddressClient CityClient StateClient Zip

Cell Phone: Client phone Email: Client email

SSN: SSN Gender: Client gender

Marital Status: Client marital status # of Dependents: Text field

Driver's License Number: Text field License Plate Number: Text field Registration Number: Text field

Are you currently employed? If so, fill out the information below with your current employer: 



If you are not currently employed... 

Are you willing to find full time employment within 15-30 days? Radio buttons

Are you wiling to abide by Hope House curfew (10 PM to 5 AM), including no overnight work? Radio buttons

Are you willing to make a 3 month commitment to the sober living home program? Radio buttons


List Emergency Contacts




Drug Use History 

Drug of choice: Client substances of choice

Do you believe you are an alcoholic/addict? Radio buttons

Last Drink/Use Date: Date Sobriety/Clean Date: Date

What is your longest period of abstinence? Text field

Are you willing to abide by the zero tolerance policy of the sober living home program? Radio buttons

Are you willing to submit to random drug tests and preliminary breath tests? Radio buttons



Treatment Information

Are you currently in treatment? Radio buttons

If so, list the treatment facility's information




12-Step Program History

What will be your primary 12 step group? 

Radio buttons

Other: Text field

Are you willing to attend 3 AA/NA/CR meetings per week (When employed Full time, if not employed full time; one meeting per day). Radio buttons

Do you currently have a sponsor? If yes, who? 

Text field

If you do not currently have a sponsor, are you willing to obtain a sponsor within 2 weeks of move in? Radio buttons

Are you willing to meet face to face with your sponsor once per week? Radio buttons



Medical History 

Are you currently being treated for any physical medical conditions? Radio buttons

If yes, please explain

Client health problems

Are you currently seeing a psychologist, psychiatrist, or mental health professional? Radio buttons

If yes, please explain

Client diagnosis

Have you ever attempted suicide? Radio buttons Date of incident? Date

Are you on any prescribed medications? Radio buttons

If yes, please list all prescriptions: 


Failure to report medications at the time of application may result in dismissal from the program

Are you willing to abide by Hope House's Restricted Medication Policy? Radio buttons



Legal History 

Are you currently involved with the legal system in any way? Radio buttons

If yes, please explain


Are you currently under parole, probation, or suspended imposition of a sentence? Radio buttons

CSO or PO Name: Text field Phone Number: Text field

Are you willing to sign a release of information for Hope House to communicate with this person? Radio buttons

Are you a registered sex offender? Radio buttons

Do you have a history of violent crimes on your record? Radio buttons

Past Legal Issues: Please indicate any past charges, convictions, prison sentences, DWI, Probations, Praoles, etc. Be complete and specific: 


Legal Status of your driver's license: 

Radio buttons

Other: Text field

Do you have a vehicle: Radio buttons

Do you have a current Driver's License, insurance, and registration: Radio buttons



Financial Information

Are you on public assistance? Radio buttons What assistance do you recieve? Text field

Cash Amount per Month: $Text field  Food Support Amount Per Month: $Text field

Medical Assistance: Text field Insurance provider and card number: Text field

Are you able to afford the sober living home's monthly guest fee of $250 (1st Month)/$350? Radio buttons

Do you have the $50 minimum move in fee? Radio buttons

How will you pay this move in fee? Radio buttons



Expectations and Responsibilities

The three absolutes that are grounds for immediate dismissal from the home: 

1. Use or possession of mood-altering substance, including alcohol 

2. Exclusive relationships between Hope House members or sex in the home

3. Any violence or threats of violence 


Are you willing to... 

1. Attend weekly house meetings on the designated evening? Radio buttons

2. Communicate with the Hope House Director concerning work, medications, and overnights? Radio buttons

3. Abide by the overnight policy? Radio buttons

- No overnights for the first 30 days

- 1 overnight per month days 31 to 90

- 2 overnights per month after 90 days

4. Comply with Hope House visitation hours? Radio buttons

- Monday through Sunday 9 AM to 9 PM 

- Sponsors, court service officers, parents, spouses, and children 

- Saturday and Sunday 1 PM to 9 PM 

- All other visitors -- Must be approved by Hope House Director ahead of time 

5. Respect your fellow house guests, the neighbors, and the Hope House Facility? Radio buttons

6. Abide by all county, city, state, and federal laws? Radio buttons



Hope House Guest Agreement

Initials Text field I understand that this application needs to be completely accurate and honest. I understand that if the application is not accurate, I may be asked to leave Hope House immediately without refund. 

Initials Text field I understand I am a guest at Hope House 

Initials Text field I understand that I must be able and capable to care for myself, comply with daily house requirements, and find employment without the need of supervision. 

Initials Text field I understand that I will be required to remain drug and alcohol free while living at Hope House. 


Hope House Guest: Signature Date: Date

Hope House Director/Representative: Signature Date: Date

Please have the following when checking into the Hope House: 

Membership Fees -- At least $50 (Check or Cash) 

Personal Toiletries 

Clothing / Personal Items (equivalent of 2 large suitcases) 

Any special food 

Medications approved by Director