House of Hope of Franklin County Inc.
Phone: 717-414-7666 Fax: 717-496-8780
230 E. Queen Street, Chambersburg, PA 17201
Email: lhateheroin@comcast.net
HOUSE OF HOPE of Franklin County -APPLICATION FOR RESIDENCY
DRUG USAGE
CURRENT LEGAL STATUS
If currently incarcerated, expected release date:
FINANCIAL STATUS
MEDICAL/PHYSICAL STATUS
MENTAL HEALTH STATUS
List any Medical Treatments/Counseling (include where and dates)
MEDICATIONS
PRIOR TREATMENT PROGRAMS
DEPENDENT CHILDREN
House of Hope Phone: 717-414-7666 Fax: 717-496-8780 230 E. Queen Street, Chambersburg, PA 17201 Email: lhateheroin@comcast.net
A journey of a 1000 miles begins with the first step to a better life.