Please share the following information regarding the child or teen's family
How many immediate family members are in your household? *
9 + members
Please list names and ages of siblings and any other household members
How much total combined income did all members of your HOUSEHOLD earn last year? *
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
Prefer not to answer
Are you or any member of your household currently receiving any of the following:
Please provide the following contact information for the best point of contact for the child or teen
Caregiver's First Name
Caregiver's Last Name
Is the above adult the child/teen's legal guardian?
If answer to above question is no, please describe your relationship with the child/teen.
Home Phone Number (enter "0" if none) *
Mobile Phone Number (enter "0" if none) *
Street Address *
Other NC County
Out of State
Zip/Postal Code *
Emergency Contact First Name (please choose someone who would be locally accessible in case of emergency at the ranch)
Emergency Contact Last Name
Emergency Contact Phone
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:
Child/Teen currently struggles with:
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)
How long has the child/teen been struggling with these issues?
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
Child/Teen Strength and Character traits (i.e. child is very compassionate)
How did you hear about Hope Reins?
Do you identify with a place of worship? If so, where?
Please list referral Agency and person if applicable
Child/Teen currently under the care of Therapist/Psychologist (name):
Please list any current diagnoses
Does the Child/Teen have any allergies? (environmental, food, medication) Please list all that apply
Please describe any physical/mental limitations
Please describe any past or present assault/aggressive behavior
Is there any history of animal abuse?
Please share anything you feel would be helpful in understanding the child/teen's situation
Please state your name below, indicating that you verify the above information is true and accurate
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