Hope House Application for Treatment Services

1
This application asks for personal and medical information, including your Social Security number. We use this information to determine eligibility for housing and treatment services.* This field is required.I understand and agree to provide this information for eligibility review.
I agree
2
Name* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Social Security Number* This field is required.
000-00-0000
5
Are you Hispanic, Latino, or Spanish origin?* This field is required.
Yes
No, not of Hispanic, Latino, or Spanish origin
Prefer not to answer
6
What is your race?* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
7
What is the best way to reach you right now?* This field is required.
My own phone
Someone else’s phone
A case manager or facility (jail, prison, hospital, etc.)
8
Contact NumberIf you are currently residing within a facility (jail, prison, hospital, detox unit), please indicate a contact person/case manager that we may contact.
Please enter another number where can reach you or leave a message.
9
If this is not your personal phone, who does it belong to?
10
If you are currently in a facility or working with a case manager, provide their name and phone number.
11
Enter another number we can try if we cannot reach you.
Please enter another number where can reach you or leave a message.
12
If we cannot reach you directly, may we leave a voicemail?* This field is required.
Yes, you may leave a voicemail and identify Hope House
Yes, but please do not mention Hope House
No, do not leave a voicemail
13
Do you have health insurance?* This field is required.
YESNO
14
What company do you have medical insurance with?
15
EmailAn email is NOT required. But if you want to pause and return to complete the form later, an email is needed.
example@example.com
16
Are you a Georgia resident?* This field is required.
Yes
No
17
Have you or a household member been evicted from federally assisted housing in the last 3 years for drug-related activity?* This field is required.
Yes
No
18
Have you or a household member ever been convicted of manufacturing methamphetamine in federally assisted housing?* This field is required.
Yes
No
19
Are you or a household member subject to a lifetime sex offender registration requirement?* This field is required.
Yes
No
20
Are you currently incarcerated?* This field is required.
Yes
No
21
If you are currently incarcerated provide the facility name and your release date.
22
Gender* This field is required.
Female
Male
Transgender
23
Are you currently pregnant?* This field is required.
Yes
No
24
How many months pregnant?
Please Select
Please Select
1-3
4-6
6+
25
Are you currently receiving prenatal care?
Yes
No
26
Do you have any children?* This field is required.
Yes
No
27
Do you have children under the age of 13?* This field is required.Only children under age 13 can live at Hope House.
Yes
No
28
Current AddressIf you do not currently have a permanent address, you may leave this question blank.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
29
County* This field is required.If you are homeless, what was the last county you lived in?
Please Select
Please Select
Augusta-Richmond
Burke
Columbia
Emanuel
Glascock
Jefferson
LIncoln
Screven
Taliaferro
Warren
Wilkes
Other
30
Living Situation: What best describes where you are staying right now?* This field is required.
Homeless
Emergency Shelter
Staying with friends or family temporarily
Jail or prison
In a hospital or detox facilty
Renting
Living in public housing
Transitional housing program
Own my own home
Other
31
Who are you currently living with?
Alone
Spouse/partner
Children
Other family members
Friends
Other
32
Do you have a valid driver's license or state ID?* This field is required.
Yes - Georgia
Yes - Out of state
No
33
ID Number
34
What is your marital status?* This field is required.
Single
Married
Separated
Divorced
Widowed
35
Child Information* This field is required.
First Name
Age
Gender
Child 1
Row 0, Column 0
Row 0, Column 1
Male
Female
Row 0, Column 2
Child 2
Row 1, Column 0
Row 1, Column 1
Male
Female
Row 1, Column 2
Child 3
Row 2, Column 0
Row 2, Column 1
Male
Female
Row 2, Column 2
Child 4
Row 3, Column 0
Row 3, Column 1
Male
Female
Row 3, Column 2
Child 5
Row 4, Column 0
Row 4, Column 1
Male
Female
Row 4, Column 2
Child 6
Row 5, Column 0
Row 5, Column 1
Male
Female
Row 5, Column 2
Child 7
Row 6, Column 0
Row 6, Column 1
Male
Female
Row 6, Column 2
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
First Name
Row 0, Column 0
Age
Row 0, Column 1
Gender
Male
Female
Row 0, Column 2
First Name
Row 1, Column 0
Age
Row 1, Column 1
Gender
Male
Female
Row 1, Column 2
First Name
Row 2, Column 0
Age
Row 2, Column 1
Gender
Male
Female
Row 2, Column 2
First Name
Row 3, Column 0
Age
Row 3, Column 1
Gender
Male
Female
Row 3, Column 2
First Name
Row 4, Column 0
Age
Row 4, Column 1
Gender
Male
Female
Row 4, Column 2
First Name
Row 5, Column 0
Age
Row 5, Column 1
Gender
Male
Female
Row 5, Column 2
First Name
Row 6, Column 0
Age
Row 6, Column 1
Gender
Male
Female
Row 6, Column 2
1 of 7
36
Do you currently have an open DFCS case?* This field is required.
Yes
No
37
What county is your DFCS case in?
Please Select
Please Select
Augusta-Richmond
Columbia County
Burke County
McDuffie County
Jefferson County
Lincoln County
Other
38
Caseworker name
39
Caseworker phone number
Please enter a valid phone number.
40
Do you currently have custody of your children?* This field is required.
Yes
No
Shared Custody
41
Are you seeking reunification with your children?* This field is required.
Yes
No
Unsure
42
Are you currently employed?* This field is required.
Yes
No
43
Employer Name
44
Do you currently receive any income?* This field is required.
Yes
No
45
Source of income?
Employment
SSI
SSDI
TANF
Child Support
Unemployment
Other
46
Total Monthly Income Amount
47
How old were you when you first used drugs or alcohol?* This field is required.
Please Select
Please Select
Under 10
10–12
13–15
16–18
19–25
Over 25
48
Which substances have you used?* This field is required.
Alcohol
Marijuana
Cocaine
Crack
Methamphetamine
Heroin
Fentanyl
Prescription opioids
Benzodiazepines
Synthetic drugs (K2/Spice)
Other
49
How have you used drugs?* This field is required.
Smoking
Snorting
Injecting
Oral
Other
50
Date of last use* This field is required.
Date
Month
Day
Year
51
How much did you use?* This field is required.
52
Do you require detox?* This field is required.
Yes
No
Unsure
53
Have you ever been to a treatment facilty before?* This field is required.
Yes
No
54
How many times have you been in treatment?
55
Where were you treated?
56
Did you leave against medical advice?
Yes
No
Unsure
57
Are you currently enrolled in another treatment program?* This field is required.
Yes
No
58
Are you currently prescribed any medication for substance use disorder (MAT)?
Suboxone / Buprenorphine
Methadone
Vivitrol
Naltrexone
None
59
Are you interested in medication-assisted treatment (MAT)?* This field is required.
Yes
No
Unsure
60
Please describe any other medical conditions we should know about.
61
List any current medications you are taking.
62
Primary physician (if any)
63
List any allergies you have.
64
Have you had a TB test in the last 6 months?* This field is required.
Yes
No
65
TB test result
Positive
Negative
Waiting on results
66
Do you have any current or past legal charges?* This field is required.
Yes
No
67
Please describe charges, dates, and current status
68
Are you currently on probation, parole, or community supervision?* This field is required.
Yes
No
69
Supervision Officer Name
70
Supervision Officer Phone
71
How often do you report?
Please Select
Please Select
Weekly
Biweekly
Monthly
Other
72
Does your officer know you are applying for treatment?
Yes
No
Not sure
73
I voluntarily consent to complete a substance use assessment administered by Hope House during the intake process. I understand this does not guarantee admission.* This field is required.
I agree
74
Consent to Verify Income Information

Why You Are Being Asked to Sign This Form

Our residential program provides housing that is paid for through a federal Section 8 housing voucher program. Because federal housing funds are being used to cover your rent, federal law requires that we verify income for anyone living in the apartment.

This income verification is required for the housing assistance only. It is not related to your treatment, your medical records, or your participation in services.

Legal Authority:
This consent is required by Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by later federal laws (42 U.S.C. 3544).

Why We Need Your Consent
To determine if you qualify for housing assistance — and to make sure your benefits are set at the correct amount — we must verify your household’s income.

By signing this form, you give permission to:

The U.S. Department of Housing and Urban Development (HUD) and this Housing Agency/Authority (HA) to contact your current and past employers to verify wages and salary.

HUD and the HA to obtain wage and unemployment compensation information from your state’s employment agency.

HUD to request certain tax return information from:

The U.S. Social Security Administration (SSA)

The U.S. Internal Revenue Service (IRS)

HUD or the HA may also contact banks or other financial institutions to confirm income information when required by law.

Federal law requires that income information be independently verified. HUD and the HA may use secure computer matching systems to compare information from these sources.

How Your Information Will Be Used
The information collected will be used only to:

Confirm your household’s income

Determine your eligibility for housing assistance

Set the correct amount of benefits

How Your Information Is Protected
HUD must protect your information under the Privacy Act of 1974 (5 U.S.C. 552a). Your income information will be kept confidential.

It may be shared only for limited, approved purposes, such as:

With other government agencies for law enforcement

With federal agencies to verify employment eligibility

With housing authorities to determine housing assistance

Tax return information has additional federal protections.

The Housing Agency must also follow all applicable state privacy laws.

HUD and Housing Agency employees may face penalties for improper use or disclosure of your information.

Private landlords or property owners cannot request or receive information through this consent form.
75
By signing below, you confirm that you understand and authorize HUD and the Housing Agency to obtain and verify income information as described above.* This field is required.
I agree
76
I declare that all information provided in this application is true and complete. I understand that false information may result in denial or removal from the program. I understand that submitting this application does not guarantee admission.* This field is required.
I agree
77
Full Legal Name* This field is required.
78
Signature* This field is required.I confirm that I have read and agree to all required authorizations and notices above, including the HUD income verification authorization, Privacy Act notice, and program consents.
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