Language
English (US)
Español
Texas Home Visiting (THV) & HOPES Application
Complete one application to screen your family for both THV and HOPES—free and voluntary for eligible families in our Texas service area.
Primary Caregiver / Parent Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Way/Time to Reach You
Email Address
example@example.com
Preferred Language
Please Select
English
Spanish
Other
Street Address
*
City
County of Residence
*
Please Select
Hardin
Liberty
Montgomery
Polk
San Jacinto
Trinity
Walker
Other (not in current service area)
Total Household Size
*
How Did You Hear About Us?
Family & Child Information
Both programs serve families expecting a child, or with at least one child age 0 through 5 (before the child's 6th birthday or kindergarten entry).
Family status
*
I am currently pregnant / expecting
I am a parent or primary caregiver of a child from birth through age 5 (before the child's 6th birthday or kindergarten entry)
Neither of the above applies to me right now
Child's date of birth or expected due date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's full name
*
Child's sex
Please Select
Male
Female
Prefer not to say
Relationship to this child/pregnancy
*
Known developmental, health, or behavioral concerns
Other Children in the Home
Other children living in the home
Leave blank if there are no other children in the home.
Child name
Sex
Please Select
Female
Male
Intersex
Other
Eligibility Screening
Services are free of charge and provided regardless of economic status. Both programs accept referrals from any source — including child welfare or other agencies — but participation itself must always be the family's own choice.
Per HHSC requirements, participants must not be court-ordered, mandated, or coerced to participate — regardless of how you were referred.
Are you entering this program voluntarily, of your own choice?
*
Yes
No
Priority Characteristics
HHSC requires that enrolled families show at least one risk factor for THV, or at least two for HOPES (for the caregiver, the child, or the household). Check all that apply — there is no penalty for checking more than the minimum.
Select all that apply.
Priority characteristics
*
Family dynamics, structure, or household conflict concern
Parenting skills concern
Social support concern
Childcare or childcare access concerns
Low-income household
Homeless, runaway, or housing instability
High stress level
Tobacco use in the home
Current or former military connection
Low school attainment – Caregiver
Low school or academic achievement – Child
Developmental delay or disability – Caregiver
Developmental delay or disability – Child
Mental health concern – Caregiver
Mental health concern – Child
Behavioral concern
Current or past alcohol or substance use/abuse history, or need for treatment
Current or past domestic or interpersonal violence
Current or past child maltreatment, abuse/neglect, or child welfare involvement
Household includes an individual who is pregnant and under 21
Consent & Signature
Consent Statement
Social Security Number
Decline Social Security Number
I decline to provide my Social Security Number
Consent Acknowledgment
*
I have read and agree to the statement above, and I consent to be screened for THV and/or HOPES voluntarily
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
Should be Empty: