Hope House Assessment - Bronx
This form serves as an assessment for Hope House staff to identify your needs and how we can best support you in the re-entry process. *Required
Program SFID
What is your Full Name
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First Name
Middle Name
Last Name
What is your date of birth?
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Month
-
Day
Year
Date
Please list your Primary Phone Number
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Area Code
Phone Number
Please list your Cell Phone Number
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Area Code
Phone Number
Email Address
*
What gender do you identify as?
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Female
Male
Prefer not to say
Other
What city/state do you currently reside in?
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How long were you incarcerated?
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What were you convicted of?
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Do you have children? If so how many and please list their ages.
*
How long have you been released from incarceration?
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How soon are you needing housing?
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Within 24 hours
1 week
30 days
60 days
Other
Education Background
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High School Diploma/GED
Associates
Bachelors
Masters
Other
What type of support do you need to successfully re-enter into society? check all that apply
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Housing
Employment
Entrepreneurial skills/traning/development
Medical services
Clothing
Food
Identification documents
Family Reunification
Other
Please describe the Other support you need
What are your short term goals? (6 months - a year)
*
What are your long term career goals?
*
How did you hear about this program?
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The LOHM Website
An LOHM employee
Social Media
Other
Could you please explain Other?
Submit
For questions please contact Melaney Batiste at melaney@thelohm.org.
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