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_______________________
Parent/Guardian___________________________________________
Referred by______________________________________________
Name Phone Number
MARITAL STATUS
Single ______ Married ______ Divorced ______ Separated ______
PREGNANCY
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___________________________
FINANCIAL
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.)
PARENTAL INFORMATION
Your Mother & Father are: Married _________ Remarried______________
Separated________ Divorced ______________
Mother’s name _________________________________________________
Address________________________________________________________
Phone number_____________ Work name & number__________________
Father’s name __________________________________________________
Address _______________________________________________________
Phone number ____________ Work name & number __________________
FAMILY HISTORY
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
EDUCATIONAL
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 __________
COMMUNITY
School organizations, clubs, extra-curricular activities you have belonged
to ____________________________________________________________
Occupations/jobs you have done __________________________________
MEDICAL
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? _________________
COUNSELING
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? _________________________
LEGAL BACKGROUND
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 _____________
SPIRITUAL
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? ________________
