FIRST NAME*

LAST NAME*

BIRTH DATE*

PHONE NUMBER*

EMAIL*:

RACE & ETHNIC IDENTITY*: HISPANIC/LATINAAMERICAN IND/ALASKA NATIVEMULTIRACIALBLACK/AFRICAN AMERICANWHITEREFUSE/UNSURE

CITIZEN STATUS*: CITIZEN OF THE USREFUGEEIMMIGRANTDACA

HIGHEST LEVEL OF EDUCATION:

CURRENTLY ENROLLED?*: YesNo

CURRENT/LAST SCHOOL:

ARE YOU CURRENTLY PREGNANT?*: YesNo

IF YES, WHAT IS YOUR DUE DATE?

ANYTHING ELSE YOU WOULD LIKE TO SHARE ABOUT YOUR PREGNANCY:

DO YOU HAVE ANY DEPENDENT CHILDREN?*: YesNo

CHILD 1:
NAME:
BIRTH DATE:
FAVORITE ACTIVITY:

CHILD 2:
NAME:
BIRTH DATE:
FAVORITE ACTIVITY:

HOUSING HISTORY & HOMELESSNESS HISTORY:

CURRENT LOCATION:
ADDRESS:
HOUSING TYPE (FAMILY HOME, APARTMENT, FRIEND’S COUCH, SHELTER, ETC):
REASON FOR LEAVING:

LOCATION:
ADDRESS:
HOUSING TYPE (FAMILY HOME, APARTMENT, FRIEND’S COUCH, SHELTER, ETC):
REASON FOR LEAVING:

LOCATION:
ADDRESS:
HOUSING TYPE (FAMILY HOME, APARTMENT, FRIEND’S COUCH, SHELTER, ETC):
REASON FOR LEAVING:

DO YOU HAVE A DRIVERS LICENSE?: YesNo

WHAT DO YOU DO FOR TRANSPORTATION?:

WHAT IS YOUR CURRENT RELATIONSHIP STATUS?* : SINGLEDATINGLEGALLY MARRIEDSEPARATEDDIVORCED/WIDOWED

WHO DO YOU CURRENTLY LIVE WITH?* : ALONESPOUSEBOTH PARENTSSINGLE PARENTGRANDPARENTFOSTER HOMEHOTEL/MOTELCARTRANSITIONAL HOUSINGEXTENDED MULTI-FAMILYFRIEND(S)OTHER

IN THE PAST 6 MONTHS HAVE YOU HAD PROBLEMS GETTING ALONG WITH: MOTHERFATHERBOYFRIENDFRIENDFIANCÉSPOUSEBROTHERSISTERCHILDRENEX

HAVE ANY OF THE ABOVE ABUSED YOU (MENTALLY, PHYSICALLY OR SEXUALLY)? IF SO, WHO?:

IS THERE ANY REASON TO BELIEVE THAT A PERSON FROM YOUR PAST OR PRESENT WOULD WANT TO HURT YOU? PLEASE EXPLAIN:

HAVE YOU EVER OR DO YOU CURRENTLY HAVE A PROTECTION ORDER (RESTRAINING ORDER) AGAINST ANYONE? IF SO, WHEN WILL IT EXPIRE?:

DO YOU HAVE BARRIERS OR SPECIAL NEEDS THAT YOU NEED HELP WITH THE ANY OF THE FOLLOWING?: ALCOHOL USECRIMINAL HISTORYDEPRESSIONDEVELOPMENT DISABILITYDOMESTIC VIOLENCEDRUGS USEENGAGED IN SURVIVAL SEXMENTAL HEALTHPHYSICAL ABUSEPHYSICAL HEALTH (ILLNESS)REFERRAL TO TREATMENTRISK OF SUICIDESELF HARMSEXUAL VIOLENCESMOKING

HAVE YOU BEEN TREATED , OR ARE YOU BEING TREATED CURRENTLY FOR EMOTIONAL OR PSYCHOLOGICAL PROBLEMS?*: YesNo

DOES ANYONE IN YOUR FAMILY SUFFER FROM ANY OF THE FOLLOWING?: NERVOUS BREAKDOWNANXIETY DISORDERPANIC ATTACKSMEMORY LOSSSUICIDE ATTEMPTSSTRANGE/PECULIAR BEHAVIORVIOLENT BEHAVIORNONE OF THESE

HAVE YOU EVER BEEN CHARGED WITH: SHOPLIFTINGFORGERYVANDALISMFAILURE TO APPEARCHILD NEGLECTCHILD ABUSETHEFTDUI/DWIOTHERNONE OF THESE

ARE YOU CURRENTLY ON...*: PROBATIONPAROLECOURT SUPERVISIONNONE OF THESE

DO YOU HAVE CHARGES PENDING AT THIS TIME?*: YESNO

FOR WHAT?:

IS THERE A WARRANT FOR YOUR ARREST?*: YESNO

HAVE YOU HAD ANY PREVIOUS ARRESTS?*: YESNO

HAVE YOU EVER BEEN INVOLVED WITH A GANG OR PARTICIPATED IN GANG ACTIVITY?*: YESNO

IF SO, HOW LONG AGO?:

DO YOU CURRENTLY HAVE PARENTING ORDERS?*: YESNO

HAVE YOU EVER BEEN INVOLVED WITH SOCIAL SERVICES?*: YESNO

WAS THIS FOR YOU OR YOUR CHILD?*: MYSELFMY CHILDBOTH

HAVE YOU EVER BEEN, OR WILL YOU BE, REQUIRED TO REGISTER WITH THE STATE AS A SEX OFFENDER?*: YESNO

IF SO, WHEN AND WHAT STATE?:

WHAT SERVICES ARE YOU INTERESTED IN AT ELEVATE HOPE HOUSE? EDUCATIONAL & CAREER GUIDANCE/GOAL SETTING (GED, PREP, RESUME BUILDING, INTERVIEW COACHING)PARENTING SUPPORT/SKILL-BUILDINGLIFE SKILLS TRAINING (BUDGETING, FAMILY MEAL PLANNING, AND MORE)

I hereby certify that to the best of my knowledge the information I have given in this application is complete and accurate.

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