Hope Reins Participant Application
Hope Reins offers free 1-1 and group sessions to kids and teens in life crisis.
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 *
Gender *
Family Information
Please share the following information regarding the child or teen's family
How many immediate family members are in your household? *
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? *
Are you or any member of your household currently receiving any of the following:
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?
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 *
Zip/Postal Code *
Your answer
Emergency Contact First Name
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:
Child/Teen currently struggles with:
Is your child currently in crisis?
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 three areas of potential growth
Child/Teen Strength and Character traits (i.e. child is very compassionate)
Your answer
How did you hear about Hope Reins?
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
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?
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 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
Please indicate your availability for participation
Submit
Never submit passwords through Google Forms.
This form was created inside of Hope Reins. Report Abuse - Terms of Service