Hope Reins Participant Application
Hope Reins offers free 1-1 and group sessions to kids and teens in life crisis.
Please share the following information regarding the child or teen who is considering participation
Date of Birth
Black or African American
Hispanic or Latino
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)
Other NC County
Out of State
Emergency Contact First Name
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:
Parental Substance Abuse
Personal Substance Abuse
Physical Limitations/Med Dx
Child/Teen currently struggles with:
Low self esteem
Is your child currently in crisis?
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 three areas of potential growth
Sense of Belonging
Child/Teen Strength and Character traits (i.e. child is very compassionate)
How did you hear about Hope Reins?
Hope Reins volunteer/staff
Word of Mouth
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
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 focusing on 1-1 sessions and are offered other programs as it is appropriate. Please read below about each program option at Hope Reins. As a participant at Hope Reins, children/teens will have the opportunity to engage in multiple programs that are best suited for his/her development needs.
Please check the program options that you or your child/teen are interested in learning more about
1-1 Sessions: these 90 minute sessions offer Hope through a customized relationship with a horse and session leader.
Group Sessions: these group sessions bring together kids facing similar circumstances in life for shared growth in one of our core development areas
Bloom: this group mentoring program for teen girls ages 13-18 is a place for gathering, growth, and leadership.
Build: this group mentoring program inspires character, leadership, and friendship in pre-teen boys ages 11-15.
Ranch Fellowship: these fellowship events are designed to offer children, teens, and families the opportunity to connect with one another and experience the ranch as a whole community.
Summer Camp: this 5-day structured program allows children the opportunity to learn the depth of God's love for them through multiple camp activities. Camp registration open in February of each year.
Please indicate your availability for participation
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