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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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* Indicates required question
Email
*
Your email
Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Gender assigned at birth
*
male
Female
Phone
*
Your answer
What is the best way to contact you?
Email
Phone
Clear selection
Where are you currently staying?
*
Your answer
Are you able to climb stairs
*
Yes
No
Are you able to take care of yourself: (prepare meals, bathe, pay your bills)
*
Yes
No
Somewhat
Do you have any mental health diagnoses? (If yes, please list)
*
Your answer
Have you ever self-harmed or had suicidal ideations? (If yes, please describe and include approximate dates)
*
Your answer
Are you currently taking any medication?
*
Yes
No
Do you have any history of substance abuse? (If yes, please explain)
*
Your answer
Source of income
*
Job
SSI
none
Other:
Income Amount? Please, list all.
Your answer
Do you have any LOCAL friend or family support?
*
Yes
No
Are you willing to participate in Bible study and worship services?
*
Yes
No
Is there anything else that you would like us to know?
Your answer
Date you complete this application
MM
/
DD
/
YYYY
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