Hope House Assessment
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
What is your Full Name
*
First Name
Middle Name
Last Name
What is your date of birth?
*
-
Month
-
Day
Year
Date
Please list your Primary Phone Number
*
-
Area Code
Phone Number
Please list your Cell Phone Number
*
-
Area Code
Phone Number
Email Address
*
What gender do you identify as?
*
Female
Male
Prefer not to say
Other
What city/state do you currently reside in?
*
Enter your city, state, and zip code
How long were you incarcerated?
*
What were you convicted of?
*
How long have you been released from incarceration?
*
What is your highest level of education?
*
Some High School (did not finish)
High School /GED
Associates Degree
Bachelors Degree
Master Degree
Other
Which Hope House are you applying for?
*
Please Select
NYC, NY
Prince Gorge County, MD
New Orleans, LA
Miami, FL
Detroit, MI
Do you have children? If so how many and list their ages.
*
What type of support do you need to successfully re-enter into society? check all that apply
*
Housing
Employment
Education
Entrepreneurial skills training/development
Healthcare/ Wellness/ Medical Services
Clothing
Food
Identification documents
Family Re-Unification
Other
What are your short term goals? (6 months - a year)
*
What are your long term goals? (2+ years)
*
Referred by:
Submit
If you have questions please contact Demetrice Morris at demetrice@thelohm.org.
Should be Empty: