HOH Pre-Screen
If you are interested in the opportunity of living at the House of Hope, a Christ-based facility, please complete the form below
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Email *
Name *
Birthdate *
Gender assigned at birth *
Phone *
What is the best way to contact you?
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Where are you currently staying? *
Are you able to climb stairs *
Are you able to take care of yourself: (prepare meals, bathe, pay your bills) *
Do you have any mental health diagnoses? (If yes, please list) *
Have you ever self-harmed or had suicidal ideations?  (If yes, please describe and include approximate dates) *
Are you currently taking any medication? *
Do you have any history of substance abuse? (If yes, please explain) *
Source of income *
Income Amount? Please, list all.
Do you have any LOCAL friend or family support? *
Are you willing to participate in Bible study and worship services? *
Is there anything else that you would like us to know?
Date you complete this application
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