Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Your Gender
*
Male
Female
Transgender
Non-binary/non-conforming
I prefer not to say
Where are you currently staying?
*
If "Other," please specify.
How long have you been staying there?
*
Reason for current living situation:
*
Have you ever applied/lived at HopeHouse OKC before?
*
Yes
No
Referred to HopeHouse OKC by:
*
List all family members who will be living with you in the HopeHouse OKC residence (including yourself):
*
Include Name/Relationship/Date of Birth/Gender/Social Security Number/Grade-School/Father's Name
If you have children, please list the name(s) and age(s) of each child:
*
Where are your children currently living?
*
Is anyone pregnant?
*
Yes
No
If yes, what is the due date?
MM
DD
YYYY
Please list any family living in the Oklahoma City area:
What has contributed to your need for transitional housing?
*
If "Other," please specify:
Please explain your current situation and why you feel HopeHouse OKC can help:
*
Do you smoke?
*
Do you or your children have any special medical needs, mental health needs, or behavioral needs?
*
Yes
No
If yes, please explain:
Have you been hospitalized in the last 2 years?
*
Yes
No
If yes, please explain:
Are you currently under care of a physician, mental health professional, and/or case worker?
*
Yes
No
If yes, please provide the name and location:
Have you ever been in drug or alcohol rehabilitation?
*
Yes
No
If yes, please provide when and the facility name:
Name of abused substance(s):
Do you participate in any of the following:
If you have a past, current, or future problem with substance abuse, you may be required to attend weekly meetings and have your attendance verified. Do you agree to this requirement?
*
Yes
No
Will you and your family agree to and maintain a no alcohol/drug (including medical marijuana) policy while residing at HopeHouse?
*
Yes
No
Have you ever been arrested for any reason?
*
Yes
No
If yes: when, where, and for what?
What was the outcome?
Acquittal, fine, conviction, etc.?
Have you served time in jail/prison?
Yes
No
If yes: where and for how long?
Please provide the dates
If yes, what for?
Are you on parole or probation?
*
Yes
No
If yes, how long?
Parole/Probation officer name:
Parole/Probation officer phone number:
(###)
###
####
Is there a warrant(s) of any kind out for your arrest at present?
*
Yes
No
I am not sure
If yes, what for?
Are you currently employed?
*
Yes
No
If yes, where?
Employer phone number:
(###)
###
####
Approximate work hours and schedule:
Employment History: provide your last 3 employment opportunities:
*
Include Employer Name/Position/Dates/Reason for Leaving
What is the highest grade level you completed in school?
*
1
2
3
4
5
6
7
8
9
10
11
12
Check all that apply:
*
If "Other," please specify:
Have you participated in any job-training programs?
*
Yes
No
If yes, please describe:
Are you currently enrolled in school, G.E.D. classes, or a job-training program?
*
Yes
No
Do you:
*
Do you have a valid driver's license?
*
Yes
No
If yes, please provide DL # and Issuing State:
If you own a car, please provide year, model, tag number, and insurance provider:
Please list all income or benefits currently received from employment, child support, SSI, etc.
*
Include the income source, monthly amount, and the monthly date received.
Do you have a current case worker?
*
Yes
No
If yes, provide their name, phone number, and social service office:
Please check all categories in which you owe money for bills/debts:
*
For every item checked above, list the amount due and if it is past due (Y/N). (Ex: Electric, $550, Y)
If you are unsure of the amount due, please list it as "unknown amount." (Ex: Electric, Unknown Amount, Y)
Please list 2 references (pastor, case worker, counselor, employer, etc.). Please do not list family members.
*
Include their Name/Address/Phone Number/Relationship to you
Who should we contact in a case of emergency?
*
Include Name/Address/Phone Number/Relationship to you
If you are selected for HopeHouse OKC, do you agree to sign a Disclosure and Authorization for Employer/Program Access to Consumer Reports (Background Check) form?
*
Yes
No
Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
