Admission Application

Hello

House of Hope exists to confront the issues of childhood sexual abuse and exploitation through awareness, training and treatment programs for girls and women.

All services are provided without regard for race, sex, creed, religion, or national origin.

Please make sure to fill out and complete the Referral Form along with your application.

Applicants must complete all Intake Forms when applying to House of Hope Girls Program.

Name

Address

DOB

SSN

Race

Applicant's Insurance Type

Insurance Policy Number

Applicant's Height

Applicant's Weight

Applicant's Eye Color

Applicant's Hair Color

Case Manager

Case Manager Name

CM Work Phone

CM Mobile Phone

CM Work Address

CM Email Address

DFCS County

DFCS Supervisor Name

DFCS Supervisor Phone

DFCS Supervisor Email Address

Youth History

Probation

Contact Number

Contact Email

County

Presenting Issues - History

Counseling

Counseling History

Indicate any of the following that apply to the youth:

Present

Thoughts of SuicidePlans for Suicide AttemptHurting Oneself DeliberatelyThoughts of Hurting Someone Else

Past

Thoughts of SuicidePlans for Suicide AttemptHurting Oneself DeliberatelyThoughts of Hurting Someone Else

Has the youth suffered any loss or separation in the past 12 months?

Education History

Current School Attending

Current Grade Placement

School Address

Does the youth have an IEP or 504 Plan?

Any problems learning to read?

Any problems learning to do Math?

Has the youth ever been enrolled in Special Education?

Health History

List any health problems for which the youth is receiving treatment:

List currently prescribed medications:

List current over-the-counter medications:

Youth's Current Doctor

Date youth last saw doctor

Does the youth have any known allergies?

If yes, please list allergies

If youth has allergies, please provide a copy of this with the latest transcripts.

Additional Youth/Family Information

Please describe the youth's strengths:

Briefly state your goals for your youth:

Briefly give a history of youth's exploitation experience:

Four Things You Should Know:

Title

Signature of Legal Custody Holder

Date

Next Form

A medical examination by a physician will be required as a part of the placement process. Financial arrangements will be discussed during the application process and finalized at the time of placement.

30 days of medication should be provided on the date of intake.

All youth are accepted on a 30-day assessment basis. Based on information gathered during this assessment House of Hope Clinical team will make an acceptance decision.

If emergency placements do not meet the criteria for sexual exploration, they will be given a discharge notification.