Application for Hope Cottages

Application for Hope Cottages

Call: (870) 204-5602

Basic Information
Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Date of Birth
Age
In Case of Emergency Contact
Relationship
Phone
Marital Status
Spouse Name
Children (Names & Ages)
How did you hear about Hope Cottages?
List any immediate family who may inquire about you (with their phone numbers)

Medical History
Are you disabled or currently seeking disability? If yes, please explain
Have you been under a doctor's care during the last year? If yes, please explain
Do you have any known allergies? If yes, please list them:
Do you take medication? If yes, list both prescription and over the counter medications
Physician name/location and phone number

Personal Information
Have you ever received treatment or counseling for emotional/psychological problems? If yes, please explain
Have you ever been hospitalized or received urgent care as a result of drug abuse and/or alcoholism? If yes, please explain
Have you ever been in a rehabilitation facility? If yes, where?
Do you have an active restraining order against another person? If yes, please explain

Personal Habits
Do you (or did you in the past) use illicit drugs?
Alcohol?
Tobacco/Nicotine?
List all drugs, legal or illegal, that you have abused
What was the first drug that you used?
At what age?
What is the longest clean/sober time that you have had? (exclude jail time)

Record
Do you currently have a warrant for your arrest anywhere in the United States? If yes, where?
Past and present charges?
How many times have you been arrested?
Are you currently on probation or parole? If yes, explain
Name of probation officer:
State: Phone:
Name of Attorney: Phone:
Do you have any outstanding fines? If yes, what is the balance on your fines? What is your monthly payment amount?
Do you have an open DHS case? If yes, in what county is that case?
Name of your case manager? Phone:
NOTE: By signing the Release of Information (below), this give Hope Cottages permission to contact your attorney, your probation or parole officer and/or your DHC case manager.

Education and Employment
What is the highest grade that you completed in school?
Do you have a high school diploma? GED?
College education? Where and when?
What kind of work experience do you have?
When did you last have a job?
What is the longest time that you have kept a job?
Is there any reason that you are unable to work? If yes, please explain
Why do you want to be accepted into Hope Cottages? (Please explain in detail)

Guest Admission Criteria
Please read & sign agreement to Admission Criteria:
1. Guest must be a female 18 years or older and have at least one or more dependent children, or have legal guardianship or power of attorney.
2. The children must have their vaccination records or current wavers on hand and/or co-operate in obtaining the necessary paperwork for safety and health care issues.
3. Guests must be homeless or at least one day from being homeless.
4. Guests must have researched all other possible living options before approaching the House of Hope or Hope Cottages for assistance.
5. Guests must be open and honest during the interview process so that the staff can best decide what the biggest needs are of the family and how the family can best be assisted.
6. Guests must be willing to go through a screening and intake process to assist with a determination for eligibility.
7. Guests must be willing to undergo a background check and pass a drug screening and child maltreatment investigation. Based on the findings of these reports individuals may (or may not) be admitted to the program.
8. Guests must be employed or working toward fulltime employment to support themselves and their families. Otherwise they must provide proof of income by means such as disability or child support programs.
9. Guests must attend all group counseling and educational sessions to work on budgeting, nutrition, parenting and employment. They will also be required to attend Celebrate Recovery. Classes will be added and changed as needed.
10. Each guest must commit to saving money by setting aside part of her income into a trust account managed by the Hope Cottages and to work at securing a permanent residence by the end of the program. The amount to be determined by the case worker and the guest.
11. Guests must be willing to undergo counseling with a counselor mandated by Hope Cottages.
12. Guests while at Hope Cottages will have access limited and all outings will have to be approved by a Hope Cottages representative
Signature*

Clear
Date Signed

Release of Information
I Full Name (write candidate's name)
understand that, to receive services from Harrison House of Hope and or Hope Cottages, these organizations must on their own behalf and on my behalf, obtain information about me from other individuals, entities, governmental agencies, charitable organizations and institutions. I wish to give Harrison House of Hope and or Hope Cottages the authority to do this without further consent from me.

Therefore I hereby authorize, allow and direct Harrison House of Hope and or Hope Cottages to request, obtain from and review any and all information about me and any of my dependents from any individual, entity, church, governmental agency, charitable organization or institution such as Dept. of Human Services Harrison Housing Authority or Circle of Life that Harrison House of Hope and or Hope Cottages in its sole discretion, deems appropriate.

I hereby authorize, allow and direct Harrison House of Hope and or Hope Cottages to provide information, whether written or oral, about the status of my application for the services of Harrison House of Hope and or Hope Cottages to any individual, entity, church, governmental agency or institution, such as Dept. of Human Services, Harrison Housing Authority, or Circle of Life as Harrison House of Hope and or Hope Cottages in its sole discretion, deems appropriate.

All persons furnished with a copy of this document by Harrison House of Hope and or Hope Cottages may rely on it without contacting me directly.
This Release of Information shall remain effective until (if the foregoing is blank or date is not filled in, this release shall remain effective for five years from the date signed).
Date of Birth: Date
Candidate's Social Security Number: SSN
Candidate's Driver's License Number: License # State: State
Signature*

Clear
Date Signed
Fill out the following if known
Candidate's Address
Names of any other dependents
Should be Empty: