WOH House Application WOMEN OF HOPE, INC. HOUSE APPLICATION WOMEN OF HOPE, INC. HOUSE APPLICATION Date of Application Name Date of Birth Address Date Housing Is Needed City County State Zip Code Phone Number Email How did you hear about us? Text Emergency Contact Are You Currently Incarcerated? Yes No Name of Facility Have You Ever Been Incarcerated? How Long? Convictions Potential Release Date Any Pending Charges Legal Status Upon Release Probation Parole Probation/Parole Officer: Name: Phone: Length of Time of Probation/Parole What was the Conviction? What Programs Did You Participate In While You Were Incarcerated? What Was The Greatest Challenge? Current Medical Needs Allergies Current Mental Health Diagnosis Date Of Diagnosis Treatment Provider: Note: You will be required to sign a release of information in order to provide continuity of care Drug(s) of choice: Age at first: Date of last use: How did you begin using? Are you currently in treatment? If Yes, please indicate where and dates and times of treatment? Have you ever had any prior substance abuse treatment? Yes No If you have had any prior substance abuse treatment, please list name of provider, date, and type of treatment (IOP, inpatient, etc.) Have you ever lived in a sober living or transitional environment in the past? Please list locations and date of residency. Do you attend 12-Step meetings Yes No If so, how many per week? Do you have a sponsor Yes No If yes, please list name and phone number Do you have any dependent children? Yes No Are you involved with children services Yes No Case Worker Do you have a valid driver's license? Yes No Do you own a vehicle? Yes No Who supports your recovery and/or re-entry efforts right now and what is their relationship to you? Please describe ant other problems or concerns in your life right now: What does Recovery mean to you? Why do you want to live in a sober living house? What do you want to accomplish while at Women of Hope? Are you currently employed? Yes No If yes, Employer's name If unemployed, are you willing to secure employment? If no, explain Please make a check mark if any of these areas apply to you Social Security/Disability Pension SSI Other Food Stamps VA Benefits Workers Comp I certify that I have read and understand the Application Packet and have completed this application honestly and to the best of my ability. Failure to disclose information on this application will result in immediate termination from residence. Applications can be completed online and electronically emailed by clicking the Submit Button below or by printing this completed form and mailing it to: Women of Hope, Inc. P.O. Box 46896 Bedford, Ohio 44146 If you have any questions Submit
