Ultimate Journey Phase One Application
First Name *
Last Name *
Date of birth *
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DD
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Email *
Street Address *
City *
Zip Code *
Primary phone number *
Secondary phone number
Gender *
Emergency contact's first & last name *
Emergency contact's phone number *
Relation to your emergency contact *
Church affiliation *
How did you hear about this class? *
Reason for taking this class? *
Have you taken other classes at House of Hope? *
Do you know any Phase 1 facilitators? If so, who? *
Do you know anyone signed up to participate in the Phase 1 program? If so, who? *
Are you seeing a therapist or counselor? If so, who? *
If so, for what reason?
Have you experienced or witnessed trauma related to any of the following: *
Required
If you checked "other", please explain:
Do you have a history of: *
If you checked "other", please explain:
Do you have a history of developmental delays and/or intellectual disabilities? *
How do you respond to triggers related to trauma? *
Have you had suicidal or self-harm thought in the last six months? *
Are you taking psychiatric medications? If yes, please list. *
What protective or support factors do you have in your life? Ex: supportive family and/or friends, active community involvement, healthy self-care practices, emotional regulation skills, access to education, etc. *
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