Hope Ministries Transitional Housing Pre-Application
Mobile-friendly pre-screening application for Hope Transitional Housing. Please complete all required details and use the phone number fields for phone entries.
Applicant Information
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Housing you applying for
*
Single Mother with kids
Single Lady with no kids
Married Couple no kids
Married Couple with kids
Single Father with kids
Applicant First Name
*
Applicant Last name
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
*
Please Select
Single never married
Married living with spouse
Married not living with spouse
Divorced
Widowed
Main Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Housing History
Where are you currently living?
*
Emergency shelter
Transitional housing
Staying with friends or family
Rented apartment or house
Own home
Vehicle
Hotel or motel
Unsheltered/outdoors
Other
Current living situation - details
When was the last time you lived on your own?
Last time lived on your own - Rent/Own
Please Select
Rent
Own
Other
Have you ever been evicted?
*
Please Select
No
Yes
Prefer not to say
Do you owe a landlord money?
*
Please Select
No
Yes
Unsure
Prefer not to say
Health Insurance and Medical History
Do you have health insurance?
*
Please Select
Yes
No
Unsure
Do you have any medical health issues?
*
Please Select
Yes
No
Unsure
Medical health issues - description
Taking medication for medical issues?
*
Please Select
Yes
No
Unsure
Medical medications - list
Do you have any mental health issues?
*
Please Select
Yes
No
Unsure
Mental health issues - description
Taking medication for mental health?
*
Please Select
Yes
No
Unsure
Mental health medications - list
Safety, Substance Use, and Legal History
Have you ever been a victim of domestic violence?
*
Please Select
Yes
No
Prefer not to say
How long ago was the last occurrence of Domestic Violence?
Have you EVER had an alcohol problem?
*
Please Select
Yes
No
Prefer not to say
Alcohol- Last Date of use.
Have you EVER had a drug problem?
*
Please Select
Yes
No
Prefer not to say
Drug of choice
Drug -Last Date of use.
Do you have any current legal issues?
*
Please Select
Yes
No
Prefer not to say
Current legal issues - description
Have you ever been convicted of a sexual related crime?
*
Please Select
Yes
No
Have you been convicted of arson?
*
Please Select
Yes
No
Education and Public Assistance
What is the highest level of school you have completed?
Please Select
No formal schooling
Elementary school
Middle school
Some high school
High school diploma or GED
Some college
Associate degree
Bachelor's degree
Graduate degree
Other
Are you currently enrolled in college?
Please Select
Yes
No
Do you have a learning disability?
Please Select
Yes
N0
Do you currently receive any of the following?
TANF
SSI
SSDI
Unemployment
Food Stamps
Child Support
Employment
Other
TANF - amount
SSI - amount
SSDI - amount
Unemployment - amount
Food Stamps - amount
Child Support - amount
Employment - amount
Employment and Child Custody
Last Time You Were Employed
Last Job Title
Do You Have Custody of All Your Children?
*
Please Select
Yes
No
Partial
Not Applicable
Custody of All Children - Explanation
Do You Have an Open DCS Case?
*
Please Select
Yes
No
Unsure
Are You Currently Pregnant?
*
Please Select
Yes
No
Unsure
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Children Details
Child 1 Name
First Name
Last Name
Child 1 Sex
Please Select
Female
Male
Intersex
Prefer not to say
Other
Child 1 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 1 Do you have custody of this child?
Please Select
Yes
No
Shared custody
Other
Child 2 Name
First Name
Last Name
Child 2 Sex
Please Select
Female
Male
Intersex
Prefer not to say
Other
Child 2 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 2 Do you have custody of this child?
Please Select
Yes
No
Shared custody
Other
Child 3 Name
First Name
Last Name
Child 3 Sex
Please Select
Female
Male
Intersex
Prefer not to say
Other
Child 3 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 3 Do you have custody of this child?
Please Select
Yes
No
Shared custody
Other
Child 4 Name
First Name
Last Name
Child 4 Sex
Please Select
Female
Male
Intersex
Prefer not to say
Other
Child 4 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 4 Do you have custody of this child?
Please Select
Yes
No
Shared custody
Other
Child 5 Name
First Name
Last Name
Child 5 Sex
Please Select
Female
Male
Intersex
Prefer not to say
Other
Child 5 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child 5 Do you have custody of this child?
Please Select
Yes
No
Shared custody
Other
Goals and Additional Information
Please describe your personal goals you would like to work towards while living at Hope
Submit
Should be Empty: