Hope Community Application for Residency
Hello! We're glad you've taken the first step towards securing a safe and supportive living environment during this important phase of your life. Our goal is to provide you with the resources, guidance, support, and accountability to help you achieve your personal goals, transition into long-term, stable housing, and live out God’s plan for your life.
Please take the time to carefully read and complete this application. The information you provide will be kept confidential and will only be used for the purpose of assessing your needs and helping to connect you with appropriate care options or resources. If something does not apply to you, simply type N/A in the blank. Unanswered questions could potentially cause a delay in the application process. We want to help you, so please fill out the application completely and truthfully.
We understand that this process may be overwhelming. We are here to assist you every step of the way, so please call or email us if you have questions, concerns, or need encouragement or prayer.
We appreciate your interest in having us be part of your journey. We're excited to meet you soon!
Hope Community Transitional Team
hopecommunity@hopecenterindy.org
463-236-5052
*FOR A PDF VERSION OF THIS APPLICATION, PLEASE VISIT HOPECENTERINDY.ORG/RESIDENTIALCARE
General
Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
What is your prefered name?
Client nickname
Do you have any nicknames or aliases?
Client nickname
When is your birthdate?
Client birthdate
What is your social security number?
SSN
What is your ID or Driver's License number?
Text field
When does your license expire?
Date
What is your race/ethnicity?
Client race
What is your height?
Text field
What is your weight?
Text field
What is your eye color?
Text field
What is your current hair color?
Text field
What is your natural hair color?
Text field
What is your blood type?
Text field
What gender were you assigned at birth?
Client gender
How do you identify?
Client pronoun
What is your relationship status?
Client marital status
Are you a veteran?
Client veteran status
Have you ever been trained in the use of firearms?
Checkboxes
Family Information
How many children do you have?
Text field
Do you currently have a case with Department of Child Services (DCS)?
Checkboxes
Are you a dependent of an active or inactive service member or veteran of the US armed forces?
Checkboxes
Contacts
Give us a few people that we can reach out to in case of an emergency.
Contact
Insurance
Enter your insurance provider(s).
Insurance
Wellness History
Tell us about your medical history.
Have you had a medical physical exam in the past year?
Checkboxes
Are you currently under a physician's care?
Checkboxes
Are you currently pregnant?
Checkboxes
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Have you had any of the following tests?
Medical Tests
Are you HIV positive or tested positive for other STDs?
Checkboxes
Please describe any physical restrictions:
Paragraph
Have you been clinically diagnosed with a mental health disorder? Add multiple by clicking in the box and selecting different options
Client diagnosis
Are you actively engaged with a licensed therapist or counselor?
Checkboxes
Please enter the information for all the health providers you're currently seeing such as your therapist, medical clinician (doctor), dentist, eye doctor, etc. List the doctor's name, clinic/hospital, and specialty. (Example: Dr. John Smith, IU Health North, Primary Care)
Therapist/Clinician
Do you have any other history of therapy or counseling?
Counseling History
Have you experiened a traumatic event that still affects your mental health?
Checkboxes
Have you ever struggled with an eating disorder?
Checkboxes
Do you currently struggle with an eating disorder?
Checkboxes
Have you engaged in self-harm?
Checkboxes
Do you currently self-harm?
Checkboxes
Have you ever attempted ending your life?
Checkboxes
Do you currently have thoughts or feelings of ending your life?
Checkboxes
If yes, do you have a plan?
Checkboxes
Do you struggle with any of the following?
Checkboxes
Have you ever experienced physical abuse?
Checkboxes
Have you ever experienced emotional abuse?
Checkboxes
Have you ever experienced sexual abuse?
Checkboxes
Are you currently fleeing a domestic violence relationship?
Checkboxes
Have you ever engaged in prostitution?
Checkboxes
Are you a survivor of sex trafficking or exploitation?
Checkboxes
If you are a survivor of sex trafficking or exploitation, would you be interested in learning about our long-term care program option, that is designed to help you establish a strong foundation for restoration and healing?
Checkboxes
When was your last relapse date? No history of substance use? Move on to the next section.
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
At what age did you first use?
Text field
What was/is your frequency of use?
Dropdown
What kind of meetings do currently you attend? Add multiple by clicking in the box and selecting different options
Client kinds of meetings attended
Do you have a sponsor?
Client sponsor
Are you willing and able to maintain sobriety?
Checkboxes
Medications
List the medications you are currently prescribed.
Medication
Treatment Centers and Residential Program History
Tell us about any treatment centers or residential programs you've previously been admitted into.
TreatmentCenterHistory
Will you or have you completed (graduated) a residential program?
Checkboxes
If yes, what is the name of the program?
Text field
Have you ever applied to live at or lived at the Hope Center?
Checkboxes
If yes, please explain: Text field
Legal History
If applicable, please list all charges filed against you, including date, resolution, and if there are any associated outstanding costs or fees.
Paragraph
Criminal History
Are you currently incarcerated?
Checkboxes
If yes, do you have a projected release date from jail/prison?
Date
Are you currently on probation?
Checkboxes
If yes, who is your probation/parole/case manager? Please include their name and phone number.
Text field
Employment & Education
Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory
If you are not currently employed, why not?
Text field
Select all the types of income you are currently receiving:
Checkboxes
List all other sources of income:
Paragraph
What is your total monthly income?
Text field
What is the highest level of education you have completed?
Checkboxes
What is the last school grade you attended?
Text field
Are you currently enrolled in college?
Checkboxes
If you are currently enrolled in college or have attended in the past, what is/was your major, degree, or trade?
Text field
Any learning disabilities? Skip if none.
Text field
Living Arrangements
Tell us about your current living arrangements
LivingArrangementHistory
Do you have reliable transportation?
Checkboxes
Do you own a car?
Checkboxes
If yes, do you have auto insurance coverage?
Checkboxes
Getting to Know You
What are you passionate about?
Paragraph
What is one thing that instantly makes your day better or always makes you smile?
Paragraph
What do you enjoy spending money on?
Paragraph
What are you most thankful for?
Paragraph
How do the people that love you describe you?
Paragraph
When you think of God, what comes to mind?
Paragraph
Have you ever accepted God into your life and/or been voluntarily baptized?
Paragraph
Do you pray, read the Bible, and/or attend church?
Paragraph
By the end of this program, what would you like to have accomplished?
Paragraph
Is there any other information you would like to share to help us know how to support you?
Paragraph
How did you find out about Hope Community?
Client Referred By
Thank you!
Thank you for your interest in joining the Hope Community family. We're humbled to be with you on this journey of growth and transformation.
By completing and signing this application, you are acknowledging that all the information you provided is accurate to the best of your knowledge. Someone from our team will let you know when we have received your application and started the review process. We may also reach out to you to clarify or for more information as we explore options together.
While we do our best to make the review process as quick as possible, bear in mind that this application does not guarantee immediate placement, as there might be a waiting list. We appreciate your understanding.
Please be assured that we're already praying for you, and we look forward to potentially having you as part of our Hope Community!
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Signature
Date: Date