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:
EmploymentHistory
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
Contact
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
TreatmentCenterHistory
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:
Medication
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
Paragraph
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:
Paragraph
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