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General Information

Date

Entrance Date

First name*

Last name

Birthday

Month

Day

Year

Age

SS Number

Facility Completed or Coming From

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Marital Status

Married

Single

Separated

Divorced

Do you have any kids? How many? What is their name and age? What is your relationship with each?

How is your relationship with your parents?

Did you graduate from High School?

Yes

No

If no, while at the House of Hope we will work together to help you obtain your GED.

Do you have a vehicle?

Yes

No

If you have a vehicle, we need a copy of your driver's license and insurance.

Copy of license received

Copy of insurance received

If license is suspended, how can we work together on getting restored?

Individual History

Do you have a substance abuse problem?

Yes

No

What was your drug of choice?

Date of last usage

How many Christian support meetings do you plan to attend each week?

Do you want to stop drinking alcohol and using drugs?

What do you plan to do to stay free of any or alcohol use?

Have you been diagnosed with any other mental / emotional problems besides substance abuse?

Yes

No

If so, what?

How do these diagnoses affect your ability to work and function in society?

Employment is a necessary part to be a resident at the House of Hope. Can you work full time?

Yes

No

If no, please explain

House of Hope is a substance-free, positive, Christian environment. Please write a brief statement about how living in the House of Hope can help you achieve your goals.

List Three Goals you would like to accomplish while at the House of Hope

1.

2.

3.

If you are currently incarcerated:

How long have you been incarcerated?

When do you plan to be released?

What type of supervision will you be under and for how long?

Arrested Record

List all of the times you have been arrested. When / Where?

List any warrants you may have

Explain more if you need it

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In Gratitude...

The Renewed Treasures Ministries would like to thank the following contributors to our website. David J. Eslick Photography provided many splendid images presented here. Brett Franklin of Quality Trim and Sign designed our handsome web banner. James S. Baumlin of Research Consultants of the Ozarks helped with the text. Jann Baker designed [and maintains] our site. To these gracious givers, we add our thanks to the pastor and congregation of Northside Assembly of God.

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