RESIDENCY APPLICATION FOR
advertisement
Dear Young Mom, Thank you so much for your interest in the Residential Program at Hope House of Colorado! The Residential program is a five phase program, designed to help you begin your path to self-sufficiency. While in this program you will: Live in community with other teen moms and their children, learning and following community components of the house (cleaning, cooking, etc). Join a team of people who are dedicated to helping you become the best mom you can be. Meet weekly for Case Management. Meet weekly for individual and group parenting sessions. Learn vital life skills in weekly Life Skills Classes (car care, healthy relationships, job readiness, etc.) Attend a Bible-based church weekly. Complete GED certification and choose an education and career path. Be awarded graduation gifts as you move through the program. Hope House of Colorado is a non-profit organization committed to helping young moms just like you. We understand the challenges that you face and want you to know that you don’t have to face them alone. If you have any questions about this program, please don’t hesitate to call; we would be glad to talk to you. Enclosed is the application for the program. Please fill it out and send it back in the self-addressed stamped envelope. You may also fax completed applications to (303) 439-2136, Attention: Hannah Winn. Once submitted your application will be reviewed and you will be contacted within 3 business days. Best wishes, Hannah Winn Residential Program Manager Hope House of Colorado (303) 429-1012 ext. 238 hannah@hopehouseofcolorado.org www.hopehouseofcolorado.org 303.429.1012 RESIDENCY APPLICATION FOR HOPE HOUSE OF COLORADO Today’s Date__________________________ Name_________________________________ Phone_______________________________ Age_______ Birth Date______________ Current Address ___________________________________________ City_____________________ State______ Zip___________ Are you a U.S. Citizen or legal resident of the U.S.? _______________________________ If no, what country are you a legal citizen of? ____________________ What is your ethnicity: (circle one) Asian Caucasian Hispanic African American Other: __________________ Children’s names and ages _________________________________ _________________________________ _________________________________ How old were you when your oldest child was born? ________________ Are you pregnant now? ________ When are you due? ______________________ Are you currently receiving TANF? _______ County _______________ Are you currently receiving food stamps? _______________ Monthly amount____________ Are you currently receiving CCAP? ______ Caseworker’s Name_______________ Are you receiving child support? _______ Amount________________________ Are you on Medicaid? _______ Case worker ________________ Are your children on Medicaid? ________ Caseworker________________ Do you have any other source of income? _______________________________ www.hopehouseofcolorado.org 303.429.1012 CHILD INFORMATION FORM One form must be filled out for each child Full name of mother____________________________ Full name of first child______________________________ Birth Date___________ Do you currently have full custody of this child? __________ If not, explain: ______________ ______________________________________________________________________ ______________________________________________________________________ Full name of father__________________________ Father’s age_____________ Father’s address_______________________________ State_____ Zip_______ Father’s phone________________________________ Does father pay child support? _______ Is it court ordered? _________ How often does he pay? ___________ Amount___________________ Father’s ethnicity___________________ Describe father’s involvement with this child_______________________________________ ______________________________________________________________________ ______________________________________________________________________ Does this child have any physical disabilities? Explain: _______________________________ ______________________________________________________________________ ______________________________________________________________________ Does child have a diagnosed learning disability? Explain: _____________________________ ______________________________________________________________________ ______________________________________________________________________ Does child have any emotional or behavioral problems? Explain: ________________________ ______________________________________________________________________ ______________________________________________________________________ Does the child have any known allergies? Explain: __________________________________ ______________________________________________________________________ Is child currently being treated by a doctor or psychologist? Explain: _____________________ ______________________________________________________________________ List child’s sibling’s names and ages____________________________________________ ______________________________________________________________________ www.hopehouseofcolorado.org 303.429.1012 CHILD INFORMATION FORM One form must be filled out for each child Full name of mother____________________________ Full name of second child______________________________ Birth Date__________ Do you currently have full custody of this child? __________ If not, explain: ______________________________________________________________________ ______________________________________________________________________ Full name of father__________________________ Father’s Age_____________ Father’s address_______________________________ State_____ Zip_______ Father’s phone________________________________ Does father pay child support? _______ Is it court ordered? _________ How often does he pay? ___________ Amount___________________ Father’s ethnicity___________________ Describe father’s involvement with this child_______________________________________ ______________________________________________________________________ ______________________________________________________________________ Does this child have any physical disabilities? Explain: _______________________________ ______________________________________________________________________ ______________________________________________________________________ Does child have a diagnosed learning disability? Explain: _____________________________ ______________________________________________________________________ ______________________________________________________________________ Does child have any emotional or behavioral problems? Explain: ________________________ ______________________________________________________________________ ______________________________________________________________________ Does the child have any known allergies? Explain: __________________________________ ______________________________________________________________________ Is child currently being treated by a doctor or psychologist? Explain: _____________________ ______________________________________________________________________ List child’s sibling’s names and ages____________________________________________ ______________________________________________________________________ www.hopehouseofcolorado.org 303.429.1012 Family History Your Mother’s Name______________________ Where does your mom work?______________ Your mom’s Address________________________ City_________________ ST____ Zip________ Home Phone____________ Work Phone____________ Cell Phone________________ Your Father’s Name______________________ Where does your father work?___________________________ Your father’s Address________________________ City_________________ ST____ Zip_________ Home Phone____________ Work Phone____________ Cell Phone_________________ Describe your relationship with your mother: ______________________________________ ______________________________________________________________________ ______________________________________________________________________ Describe your relationship with your father: _______________________________________ ______________________________________________________________________ ______________________________________________________________________ Do your parents still live together? _______________ If your parents are separated, whom do/did you live with? Mom ________ At what ages? ____________________ Dad __________ At what ages? ___________________ Other (Name and Relationship) ______________________ At what ages? _________ List your brothers and sisters (indicate if this is a step/half brother or sister) Name _____________________________ Age____________ Address____________________ Name _____________________________ Age____________ Address____________________ Name _____________________________ Age____________ Address____________________ Name _____________________________ Age____________ Address____________________ www.hopehouseofcolorado.org 303.429.1012 List any relatives you are close to: Name________________ Relationship_____________ Phone _________________ Name________________ Relationship_____________ Phone _________________ List any friends you are close to: Name_________________________ Phone__________________ Name_________________________ Phone__________________ Personal History Educational Background Grade last completed______ Do you have a G.E.D. or diploma? __________________ Where did you attend high school? _________________________________________ How many schools did you attend during the course of elementary, middle and high school? _____________________________________________________________________ College/Vocational training _______________ Where _____________________________ Are you currently attending school? If yes, where? __________________________________ Work History List last three places of employment, starting and ending dates, and reason for leaving your job Where________________________________ When__________________________ Reason for leaving_______________________________________________________ Where________________________________ When___________________________ Reason for leaving_______________________________________________________ Where________________________________ When___________________________ Reason for leaving_______________________________________________________ Are you currently working? _________________ Where __________________ Hourly Wage_____________ How many hours per week? ___________________ Church History What are your thoughts about God? Do you go to church regularly? ______ Church Name? ___________ Do you attend with family members? _______ List names and relationships________________ ______________________________________________________________________ www.hopehouseofcolorado.org 303.429.1012 Relationship History Are you: ______Married _____ Single Are you currently dating someone? ______ Name and Phone_________________________ Is he the father of your child/children? _________________________________________ If not, describe your relationship with the father of your child/children (include his full name) ______________________________________________________________________ ______________________________________________________________________ How long were you together? _______ How would you describe him? ____________________ ______________________________________________________________________ Domestic Violence History In the last six months, have you had problems getting along with: Mother_____ Father____ Brother/Sister________ Other family member_________ Have any of these people ever abused you (list relationship)? a.) Emotionally (made you feel bad through harsh words or verbal intimidation) _____________________________________________________________________ ______________________________________________________________________ b.) Physically (caused you physical harm):________________________________________ ______________________________________________________________________ ______________________________________________________________________ c.) Sexually (forced to have sex, or been touched in area/ways you didn’t want to be): ______________________________________________________________________ ______________________________________________________________________ Has a past or present boyfriend ever: a.) Hit, pushed, or physically intimidated you______________________________________ ______________________________________________________________________ b.) Verbally abused you, threatened you, or intimidated you____________________________ ______________________________________________________________________ c.) Forced you to have sex or perform sexual acts against your will________________________ ______________________________________________________________________ www.hopehouseofcolorado.org 303.429.1012 Have you ever, or do you currently have a restraining order against anybody, and if so, why did you get it________________________________________________________________ ______________________________________________________________________ Is there any reason to believe that a current or past boyfriend or family member would want to hurt you? Explain: _______________________________________________________________ ______________________________________________________________________ Legal History How many times in your life have you been charged with: _______ Shoplifting _______ Vandalism _______ Forgery _______ Child Neglect _______ Failure to appear _______ DUI/DWI _______ Theft _______ Child Abuse _______ Other Are you currently on probation_____, parole______, or court supervision_________? Explain: _______________________________________________________________ ______________________________________________________________________ Are you currently awaiting charges_______, sentencing_______, or trial__________? Explain: _______________________________________________________________ Is there currently a warrant out for your arrest?_____ Explain: __________________ ______________________________________________________________________ Do you have charges pending? ________________________________________ Charge Court Date Location ____________________ _________________ ___________________ ____________________ _________________ ___________________ ____________________ _________________ ___________________ Have you had previous arrests? ______What were the charges and when were they filed? Charge __________________ __________________ __________________ Date __________________ __________________ __________________ Do you have any outstanding traffic tickets? Explain: ________________________________ www.hopehouseofcolorado.org 303.429.1012 Have you ever been in jail or a juvenile detention program? _________ Explain, including dates and reason: _____________________________________________________________ Are you currently involved with Social Services? __________ Explain (include caseworker’s name and county): _____________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Have you ever been, or will you be, required to register with the state as a sex offender? _______If yes, explain _____________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Housing History In the last year, what were your usual living arrangements? Check all that apply. _____ With family _____Alone ____ Boyfriend _____With friends ______ In a shelter ______ Other _____ Group home _____ No stable home How many times have you moved in the past year? ______________________ How many times have you moved since you were born? ______________________Have you ever lived in a group home? _______ Name of the home or facility?______________ _____________________________________________________________________ _____________________________________________________________________ List dates and your age_____________________________________________________ _____________________________________________________________________ Have you ever been in foster care? ____________________________________________ How many foster homes have you been in? ______________________________________ List dates and your age for each_______________________________________________ _____________________________________________________________________ Practical Supports What do you do for transportation? ____________________________________________ Do you have a driver’s license? _____________ State I.D? ___________________ Do you have a copy of your birth certificate?____ Your children’s birth certificates?_______ Do you have a Social Security card? _____ Your children’s Social Security cards? ______ www.hopehouseofcolorado.org 303.429.1012 Substance Abuse Do you currently smoke? ________ Have you ever smoked? ________________________ List the date that you started smoking ___________ and stopped smoking _____________ How many times in the last three months have you used: _________Alcohol _________ Cocaine _________Marijuana _________ prescription drugs/painkillers Amphetamines _________ Other At what age was your first alcohol use? __________________ Describe your alcohol use (recreational, when alone, at parties, etc) ______________________ ______________________________________________________________________ Have you ever been treated for an alcohol or drug problem before? _____________ Specify: ________ Alcohol _________ Drug Which drug? __________________________ If yes, complete the following: a.) Detoxification only___________ How many times? __________ Place and Dates ________ ______________________________________________________________________ Did you complete treatment? _____ If no, explain: __________________________________ ______________________________________________________________________ b.) Rehabilitation__________ How many times? ___________ Places and Dates __________ ______________________________________________________________________ Did you complete treatment? ______ If no, explain:_________________________________ ______________________________________________________________________ c.) Outpatient Therapy_________ How many times? __________ Places and Dates _________ ______________________________________________________________________ Did you complete treatment? ______ If no, explain: ________________________________ Have you ever had an alcohol or drug use evaluation? _________ Explain: ________________ ______________________________________________________________________ Are any of your immediate family members alcoholics? _________ List relationship__________ ______________________________________________________________________ Are any of your immediate family members addicted to drugs? ________ List relationship ______________________________________________________________________ Are any of you close friends alcoholics? ________ Addicted to drugs? ___________ Do you think that you may have a current problem with drug or alcohol use that has so far gone untreated? _____Explain: _______________________________________ _____________________________________________________________________ www.hopehouseofcolorado.org 303.429.1012 Medical History Do you have any physical disabilities? Explain:________________________________ ______________________________________________________________________ Are you currently being treated by a doctor? Explain:___________________________ ______________________________________________________________________ Do you have any known allergies? Explain: ___________________________________ ______________________________________________________________________ Are you on Birth Control? ___________ If so, what type?_______________________ When was your last trip to the emergency room? _ ________________ What were you seen for and what was the treatment given? _________________________________________________________________ ______________________________________________________________________ Mental Health History Does anyone in your family (specify relationship) suffer from the following: ___________ nervous breakdown ___________ depression ___________ strange/peculiar behavior ___________suicide attempt ___________ anxiety disorder ___________ memory loss ___________ violent behavior ___________ panic attacks Has anyone in your family ever been diagnosed with a mental disorder? __________ Specify who, and what disorder ___________________________________________ How many times in the last three months have you experienced the following (check all that apply): ___________ anxiety or tension ___________ depression ___________ suicide attempts ___________ thoughts of suicide ___________ wanting to harm yourself ___________ panic attacks ___________ trouble controlling violent behavior ___________ trouble understanding, concentrating, or remembering things Are you now being treated, or have you ever been treated, for emotional or psychological problems? Details: ______________________________________________________________ ____________________________________________________________________ Have you ever been prescribed medications to be taken for an emotional or psychological problem? _______ Dates___________________ Medicine prescribed____________________ Name of doctor or clinic that wrote the prescription______________________ www.hopehouseofcolorado.org 303.429.1012 Are you currently taking any medications for an emotional or psychological problem? ______ Name and dosage of medication_____________________________________ Name of doctor or clinic that prescribed it____________________________________ Have you ever attended counseling? ________ Are you currently seeing a counselor? ______ If so, list counselor’s name_________________________________ Have you ever been diagnosed with an eating disorder? ______ Specify __________ Have you ever used laxatives, strenuous exercise or self-induced vomiting to lose weight? _______ Explain: ________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ESSAY QUESTIONS Please answer these questions as thoroughly as possible. Take your time and use the back of these sheets if necessary. Some of these questions may have been asked elsewhere in this application, but this form gives you the space to share additional details. 1. Have you ever been involved in gang activity? Explain. 2. Have you ever been physically, emotionally, or sexually abused? How old were you? How do you believe it has affected you life? 3. Do you see yourself repeating these abusive behaviors toward your own children in some manner? 4. Describe your childhood. (i.e. safe/unsafe, healthy/unhealthy, lonely, happy, etc) www.hopehouseofcolorado.org 303.429.1012 5. How do you feel about your life today? (Fearful, anxious, stressed) 6. What do you do when you feel anxious or upset? 7. How have you coped with crises in the past? 8. Has drinking or drug use ever been a way to cope? 9. Have you ever been hit or beaten by a current or ex-boyfriend (even if you feel that you started it or that you were behaving violently yourself)? 11. Who do you count on for emotional support? 12. Who do you rely on to watch your child/children for you? 13. Whom do you consider to be your closest friends and what makes them a good friend? www.hopehouseofcolorado.org 303.429.1012 14. How long have you been sexually active? 15. Do you believe that you may be homosexual or bisexual? 16. Have you ever, or do you currently, have a fascination with pornography? With sexual experiences over the Internet? 17. Have you ever attempted suicide? How old were you? Explain what happened: 18. Have you ever abused yourself? (i.e. cutting) How old were you? Explain: 19. Describe your religious background and beliefs: 20. Have you ever had a bad experience with a church? Explain: www.hopehouseofcolorado.org 303.429.1012 21. Have you ever been involved with a cult? Explain: 22. How do you typically respond to authority or authority figures (teachers, police officers, a boss)? 23. How do you deal with anger (How do you act when you are angry)? 24. List your hobbies and interests. 25. What do you feel is the cause of your current difficulties? www.hopehouseofcolorado.org 303.429.1012 Please tell us why you wish to live at Hope House. What are your goals? Where would you like to see yourself in two years? Five years? I hereby certify that to the best of my knowledge the information I have given in this application is complete and accurate. ____________________________________ Signature ________________ Date www.hopehouseofcolorado.org 303.429.1012 LIST OF REFERENCES 1. Name:__________________ Phone: _______________ Relationship:_________________ 2. Name:__________________ Phone: _______________ Relationship:_________________ 3. Name:__________________ Phone: _______________ Relationship:_________________ List any additional references, including organizations (Teen MOPS, another group home, etc.) and individuals (teacher, pastor, counselor, etc). List name, role in your life and phone number. 1._______________________________________________________________ 2._______________________________________________________________ 3._______________________________________________________________ 4._______________________________________________________________ I hereby give permission for the above references to give information about myself to the staff of Hope House of Colorado. I also release Hope House from confidentiality regarding said information, for the purpose of determining my acceptance as a resident. ____________________________________ Signature www.hopehouseofcolorado.org 303.429.1012 __________ Date
