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Hope Reins Participant Application
Hope Reins offers 1-1 and group sessions at no cost to kids and teens in a life crisis.
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Participant Information
Please share the following information regarding the child or teen who is considering participation
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Ethnicity
*
Black or African American
White
Hispanic or Latino
Asian
Native
Pacific Islander
Multiple Race
Other
Gender
*
Choose
Male
Female
Family Information
Please share the following information regarding the child or teen's family
How many immediate family members are in your household?
*
Choose
1 member
2 members
3 members
4 members
5 members
6 members
7 members
8 members
9 + members
Please list names and ages of siblings and any other household members
Your answer
How much total combined income did all members of your HOUSEHOLD earn last year?
*
Choose
less than $12,140
$12,141 - $16,460
$16,461 - $20,780
$20,781 - $25,100
$25,101 - $29,420
$29,421 - $33,740
$33,741 - $38,060
$38,061 - $42,380
$42,381 - $46,700
$46,701 - $51,020
$51,021 - 74,999
$75,000 - $99,999
$100,000 - $124,999
$125,000 - $149,999
$150,000 - $174,999
$175,000 - $199,999
$200,000+
Prefer not to answer
Are you or any member of your household currently receiving any of the following:
Food Stamps
TANIF
SSI
Medicaid
Medicare
Contact Information
Please provide the following contact information for the best point of contact for the child or teen
Caregiver's First Name
Your answer
Caregiver's Last Name
Your answer
Is the above adult the child/teen's legal guardian?
Yes
No
Clear selection
If answer to above question is no, please describe your relationship with the child/teen.
Your answer
Home Phone Number (enter "0" if none)
*
Your answer
Mobile Phone Number (enter "0" if none)
*
Your answer
Email
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
County
*
Choose
Wake
Durham
Orange
Franklin
Granville
Halifax
Johnston
Moore
Nash
Person
Pitt
Other NC County
Out of State
Zip/Postal Code
*
Your answer
Emergency Contact First Name (please choose someone who would be locally accessible in case of emergency at the ranch)
Your answer
Emergency Contact Last Name
Your answer
Emergency Contact Phone
Your answer
Participant Description
This section will help us have a better understanding of how we may best serve the child or teen
Child/Teen has a history of:
ADHD
Adoption
Anger
Anxiety
Bullying
Community Violence
Conflict
Depression
Domestic Violence
Emotional Abuse
Family Divorce
Family Separation
Foster Care
Frequent Relocation
Gangs
Grief
Labor Trafficking
Learning/Cognitive/Disability
Loss
Military
Neglect
OCD
ODD
Parental Death
Parental Incarceration
Parental Substance Abuse
Personal Substance Abuse
Physical Abuse
Physical Limitations/Med Dx
PTSD
School Violence
Self Harm
Sex Trafficking
Sexual Abuse
Suicide Attempts
Suicide Ideation
Suicide Threats
Traumatic experience
Truancy
Verbal Abuse
Other
Child/Teen currently struggles with:
ADHD
Anger
Anxiety
Conflict
Depression
Destructive behaviors
Empathy
Grief
Learning Disability(s)
Low self esteem
OCD
ODD
PTSD
Relationships
School performance
Self Harm
Self Talk/Self Worth
Sensory Processing
Suicidal Ideation/Threats
Suicide Attempts
Other
Do you feel your child is currently experiencing a crisis? (for example: isolation, depression, anxiety, missing school or struggles in performing daily functions, suicide ideation or attempts)
Choose
Yes
No
Not sure
How long has the child/teen been struggling with these issues?
Your answer
Child/Teen Potential Areas of Development
Hope Reins' programs are designed to help children grow and develop emotionally, spiritually, physically, relationally.
Please identify the top five (5) outcomes you hope to see in the participant
Boundaries
Comfort
Communication
Confidence
Empathy
Improved Participation in School/Home Life
Improved Relationships
Improved Self Talk/Feelings
Leadership
Listening Skills
Respect (self/others)
Respite
Responsibility
Self Control
Self Esteem
Self Expression
Sense of Belonging
Sense of Purpose
Sense of Safety
Sense of Value/Worth
Social Skills
Trust
Other
Child/Teen Strength and Character traits (i.e. child is very compassionate)
Your answer
How did you hear about Hope Reins?
Church
Drove-by
Radio
Hope Reins Volunteer/Staff
Internet
Social Media/News/Radio
Referral/Partner
Therapist/Counselor
Word of Mouth
Other
Clear selection
Do you identify with a place of worship? If so, where?
Your answer
Please list referral Agency and person if applicable
Your answer
Child/Teen currently under the care of Therapist/Psychologist (name):
Your answer
Please list any current diagnoses
Your answer
Does the Child/Teen have any allergies? (environmental, food, medication) Please list all that apply
Your answer
Please describe any physical/mental limitations
Your answer
Please describe any past or present assault/aggressive behavior
Your answer
Is there any history of animal abuse?
Choose
Yes
No
Please share anything you feel would be helpful in understanding the child/teen's situation
Your answer
Please state your name below, indicating that you verify the above information is true and accurate
Your answer
Program Information and Availability
Participants begin Hope Reins 5 step program pathway with weekly 1:1 sessions. After each step, new elements are integrated into the participant’s experience- including peer mentorship groups and skill base group sessions.
Please indicate your availability for participation
Monday Afternoon/Evening
Tuesday Afternoon/Evening
Wednesday Afternoon/Evening
Thursday Afternoon/Evening
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