Download HH Admission Application

  Hope House – Admission Intake Application

This information is confidential. Please answer honestly so we may know best how to help you.

Name _________________________________________________
Last First Middle Maiden

Current Address__________________________________________
Street City State Zip

Current Phone Number_____________________________________

Date of Birth__________ Age______

City/State of Birthplace_____________________________________

Social Security #_________________ Driver’s License#___________

Person living with & relationship to them_______________________


Referred by______________________________________________
Name Phone Number


Single ______ Married ______ Divorced ______ Separated ______


Are you pregnant?__________ Approximate due date _________________

Documentation of pregnancy _______ Currently under medical care_____

Doctor’s Name /Address/Phone ___________________________________

Any Problems with your current pregnancy _________________________

Number of times pregnant _______How many births__________________

How many abortions ________ How many miscarriages________________

Explain any past complications with pregnancy, labor, & delivery


If you have children, who has custody of them_______________________

Future plans for the baby: Adoption________ Parenting yourself________

Unsure_______ Other____________________________________________

Information of birth father: Name_________________________________

Address __________________________ Phone ______________________

Is he aware of pregnancy? ________

Briefly explain situation with birth father___________________________


Do you have outstanding debts? _______ How are you paying them? ____


Medical Insurance? _________ Carrier__________________ ____________

Policy #________________________________________________________

Need to apply for Medicaid? ______________________________________
(Hope House provides food & shelter, but we are not responsible for other expenses such medical care & prescriptions.)


Your Mother & Father are: Married _________ Remarried______________

Separated________ Divorced ______________

Mother’s name _________________________________________________


Phone number_____________ Work name & number__________________

Father’s name __________________________________________________

Address _______________________________________________________

Phone number ____________ Work name & number __________________


How do you feel about your mother? _______________________________

How do feel about your father? ___________________________________

List your sister(s) and brother(s) __________________________________

Name Age Address Phone

Name Age Address Phone

Name Age Address Phone

Name Age Address Phone

How do you feel about your sister(s) and brother(s)? _________________

How do you feel about your boyfriend/husband? _____________________

Were your parents/husband/boyfriend abusive? ______ If yes, explain


Name of last school attended _____________________________________

Last grade completed ______Average grades ________________________

When graduated? _______________________________________________

What are your favorite subjects in school? __________________________

Age dropped out of school ______ Why dropped out __________________

What have you been doing since you dropped out of school? ___________

Do you have a G.E.D.? ___________________________________________

Explain any special learning needs or problems ______________________

Have you had any college or career training _______ Explain __________


School organizations, clubs, extra-curricular activities you have belonged

to ____________________________________________________________

Occupations/jobs you have done __________________________________


Are you having dental problems? ______ Do you have dental insurance? _

Insurance Company __________________ Policy Number ______________

Are you having vision problems? ___________________________________

Do you wear glasses or contacts ___________________________________

Menstrual cycle: Date of last period _______________________________

Current medications (list & why taking) ____________________________

Allergies to medications (specify type & outcome) ___________________

Allergies to other products (List type, i.e. food,detergents, plants, animals, soaps, ect.) and outcomes ________________________________

Explain any illness or chronic health conditions ______________________

Please indicate if you have had or are having any of the following:
Yes No Unsure
Chicken Pox Y N U Measles Y N U
Mumps Y N U Rubella Y N U
Tuberculosis Y N U HIV + Test Y N U
Hepatitis Y N U Blood
Transfusions Y N U
Rashes Y N U Depression Y N U
Eye infection Y N U Ear problems Y N U
Convulsions Y N U Epilepsy Y N U

Are you on a special diet? _____ Explain _____________________________

List all past surgeries (include dates) ________________________________

Have you ever used illegal drugs? _____ Are you currently using them? ___

When was the last time you took them? ______________________________

Do you use alcohol? _______ How much do you drink a day? _____________

Have you ever been treated for a drug or alcohol addiction? ____________

If yes, when & where did you complete treatment? ____________________

Do you smoke? _________ How many cigarettes a day? _________________


Have you ever been to counseling? _____ When/Where ________________

Purpose: ________________________________________________________

Have you ever received psychiatric care or been in a mental institution?

________When _________Purpose __________________________________

Have you ever been in a program? _____ When/Where _________________

Religious? _______________ Non-religious? ___________________________

Have you ever tried to commit suicide? ______________________________

When/Why ______________________________________________________

Discuss treatment received, if any __________________________________

Have you ever been a victim of rape or incest? ________________________

Have you ever been involved in prostitution? _________________________


Have you ever been arrested? _____ How many times? _________________

List dates and charges ____________________________________________

Have you ever been on probation or parole? __________________________

How long? ________ Time remaining ________________________________

How often do you report? __________________________________________

Probation/Parole officer __________________________________________

Address _____________________________________ Phone _____________


Have you been involved in any of these practices, if yes, please explain:

Astroprojection _______________ Satanic worship ________________
Divination ___________________ Seances ______________________
Fortune Telling _______________ Spell Casting __________________
Horoscopes ___________________ Tarot Cards ___________________
Levitation ____________________ Voodoo _______________________
Ouiji Boards __________________ Witchcraft ____________________
Palm Reading _________________ Yoga _________________________

Have you been involved in these groups/religions, if yes, please explain

Christian Science ______________ Mormonism ___________________
Eastern Religions ______________ Scientology ___________________
Jehovah’s Witness _____________ Transcendental meditation ______
Brotherhood __________________ New Age Movement ____________

Name of church attended during youth ______________________________

Are you a Christian? ________ When (date) __________ Your age ________

How often do you read the Bible? ___________________________________

How often do you pray? ___________________________________________

What is your present relationship with God? __________________________

Do you feel you have need for God? _______ Explain ___________________

In general how do you feel about yourself? ___________________________

Why do you seek admission to the Hope House? _______________________

What would you like to happen while you are here? ___________________

What are your plans for yourself after the baby is born? ________________