HHD Program Application

Program Application
How did you hear about us?*

Returning to our programReferral of current clientReferral of past clientOrganizationInternet SearchNone of the above
Person or organization that referred you:
Applicant Information
Full name*

First NameLast Name
Gender*

MaleFemale
How soon are you looking to begin our program?*
Please provide a date if you know it

MonthDayYear
Email
Phone number*
Date of birth

MonthDayYear
How long have you been sober?*
Have you been charged of a sexual offense?*

YesNo
Are you currently on probation or parole?*

YesNo
If you are on probation or parole provide the contact information for the officer

First NameLast Name
Phone Number for parole or probation officer
Drug(s) of choice (check all that apply)*

AlcoholAmphetaminesCocaine / CrackHallucinogensHeroinMarijuanaMethamphetamineOpiodsOther
If you selected "Other" please provide details:
If you are currently participating in a detox program or an inpatient treatment center please provide the facility name?
If you are currently residing in another sober community please provide the name and location of the sober community
If you are currently residing in another sober community, how would you rate it? (We use this information to recommend communities when we are at full occupancy.)

1

2

3

4

5

1 is Would not recommend, 5 is Excellent
Have you been diagnosed with the following mental health disorders:*

Bipolar - Type 1Bipolar - Type 2SchizophreniaI have not been diagnosed with Bipolar or Schizophrenia
Please provide a full list of current medications with dosage:
Emergency Contact
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Please notify my emergency contact if:

I have a medical emergency (not alcohol or drug related)I have a medical emergency (alcohol or drug related)I am intoxicated and I have been asked to leave the programAll of the above
Ready for Change
Rate your readiness for change:*

1

2

3

4

5

1 is Not at all ready / doing this for someone else, 5 is Willing to do anything
What is motivating you to change?
What do you need the most help with?*

AccountabilityAffordabilityGetting to know more sober peopleEverything (Being sober is new to me, help!)Other
If you selected "Other" please explain:
Is there anything else you would like us to know as we consider your application?
What you should know about us
The House of Hope and Dreams is a privately owned community that does not receive any government assistance. I understand that it is my responsibility, as the applicant, to pay the program fees or I will be asked to leave the community.*

Yes, I understandNo
I understand that as part of living in this sober community that I will be asked to provide a urine sample once a week or more. I understand that the collection of the sample I provide may be witnessed by a manger of the same sex to ensure that the sample is mine and current. In addition to urine samples, I may also be asked to blow into a breathalyzer to confirm I am complying with the sober requirements.*

Yes, I understandNo
I understand that if I am providing a urine sample that is not mine, not current, or synthetic in any way, I will be asked to leave the community immediately.*

Yes, I understandNo
I understand that I will be asked to leave the community immediately if I am found under the influence of drugs or alcohol. If I violate the community policy by using drugs or consuming alcohol I will forfeit my program fees for the week.*

Yes, I understandNo
I understand that during the intake process I will be asked to review additional policies including curfews, work requirements, cleanliness requirements, etc.*

Yes, I understandNo
Terms and Conditions for Text Communications: You agree to receive customer care text messages from the House of Hope and Dreams. Message frequency varies. Message and data rates may apply. SMS consent is not shared with third parties or affiliates for marketing purposes. For help, reply HELP or email us at info@houseofhopeanddreams.com. Reply STOP to unsubscribe*

Yes, I understandNo
Privacy Policy for Information Collected: We do not share information collected with any third parties. Your information is used only to evaluate you as a candidate to our program. For help, email us at info@houseofhopeanddreams.com.*

Yes, I understandNo
Signature*

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Please provide any information that helps us get in touch with you to discuss next steps:
We are so excited that you decided to reach out to us! Someone will reach out soon!

Program Application

Applicant Information

Emergency Contact

Ready for Change

What you should know about us

Ready to move forward?