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His Hope Recovery Residence Application
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Name
*
Please include first and last name
Your answer
Find out if you qualify. Please check all boxes that apply to you
*
I am a male and at least 18 years old
I am serious about life transformation and open to living in a Christian environment
I am physically able to work up to 8 hours a day and able to participate in activities, including but not limited to landscaping tasks, chores, and exercise
I have not been court ordered to enter His Hope
I do not have any sex or arson charges in the past or present
I do not have a court date or other appointments scheduled for the first 30 days that I will be at His Hope
I do not have any active warrants
I do not have any probation/parole appointments that I will have to go to in-person for at least the first 30 days. Non-reporting or phone reporting appointments are fine.
I am not on any of the following prescription medication: suboxone, subutex, sublocade, methadone, narcotic pain medications, narcotic-like pain medications. Some psychotropic medications are accepted.
Required
Phone Number
*
Your answer
Email
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Current Zip Code
*
Your answer
What inpatient treatment facility are you currently at?
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Type “N/A” if you are not currently in treatment
Your answer
Who is your case manager?
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Type “N/A” if you do not currently have a case manager
Your answer
When did you enter inpatient treatment?
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Type “N/A” if you are not currently in treatment
Your answer
When do you plan on graduating from inpatient treatment?
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Type "N/A" if you are not currently in treatment
Your answer
What is/was your drug of choice?
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Your answer
When was the last time you used?
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Your answer
Do you use nicotine?
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Yes
No
Do you have any past or current mental health diagnosis? If yes, please provide your diagnosis and when you were diagnosed
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Type “No” if you do not have any past or current mental health diagnosis.
Your answer
List any prescription medications that you are currently prescribed
*
Type “none” if you are not currently on prescription medications
Your answer
Do you have insurance? If yes, who is your provider.
*
Type “no” if you do not have an insurance provider
Your answer
If you are unable to work please explain why?
Your answer
Are you currently employed? If yes, where at?
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Type “no” if you are not currently employed
Your answer
Do you have any Court, Probation or Children's Service cases that are currently open? If yes, what county are your services in?
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Type “No” if you do not have any
Your answer
Do you have any upcoming court dates?
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No
Yes, within 30 days after completing inpatient treatment
Yes, longer than 30 days after completing inpatient treatment
Are you currently on probation/porale?
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No
Yes, I am on probation/parole and have to report in-person
Yes, I am on probation/parole and I do not have to report in-person
Do you have any special needs, allergies, requests, or concerns that we need to be aware of?
Your answer
Why do you want to live at His Hope Recovery Residences
*
Your answer
How did you hear about His Hope?
*
Friend and/or Family
Former or Current Resident
Referral from Treatment Facility
Church or Religious Organization
Internet or Social Media
Literature
Required
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This form was created inside of His Hope Teen Challenge Inc..
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