Family Application | Miriam's Hope

Family Application

Person completing this form:

Date:

Applicant referred by:

Agency

Phone number:

Applicant Identifying Information

Applicant's Full Name

Birthday:

Current Address

City

State

Zip Code

Best phone number(s) to reach you:

Gender

Marital status:

Have you ever been in foster care?

Children

Are you expecting?

If yes, what's the estimated due date?

List the name(s) of your children

Child's name (Child 1)

Date of birth:

Gender

Child's name (Child 2)

Date of birth:

Gender

Child's name (Child 3)

Date of birth:

Gender

Child's name (Child 4)

Date of birth:

Gender

Do you have legal custody of your children?

If no, do you have visitation rights?

Do they live with you?

If no, where do they live?

Living Situation

Current living situation. Mark all that apply.

Risk of being homeless. Couch surfing. Friend's/Family's residence. Residential program.

I've been told I need to be out by

Reason why I need to leave this place:

If you are homeless, where are you living?

On the streets In a vehicle Shelter Other

Support System

List the three people you can count on the most.

Name (1)

Relationship

Date of birth

Address

Phone number:

Name (2)

Relationship

Date of birth

Address

Phone number:

Name (3)

Relationship

Date of birth

Address

Phone number:

Employment Information

Employment status

Full time Part time Seasonal Sporadic Unemployed

If employed, where?

If employed, how long have you been there?

If employed, how many hours per week?

If employed, what is your wage?

If unemployed, what is your situation?

Looking for work Unable to work Not looking

If you are unable to work or not looking, indicate why.

Are you in vocational rehab?

If yes, who is your worker?

Please list your last three jobs, starting with the most recent.

Employer (1)

Dates worked

Wage

Position

Why you left?

Employer (2)

Dates worked

Wage

Position

Why you left?

Employer (3)

Dates worked

Wage

Position

Why you left?

Financial Information

Do you have any of the following? Mark all that apply.

SNAP Medicaid WIC SSI SSA Other

Have you filed for unemployment?

Do you currently have a bank account?

Do you currently have any outstanding debts?

If yes, please explain.

Education and Training Information

Have you graduated from high school or attained a GED?

If you have, what year?

What school?

Are you currently attending college, vocational training, or job training?

If so, where?

Children's School History

Child's name (Child 1)

School attended

Grade

Child's name (Child 2)

School attended

Grade

Child's name (Child 3)

School attended

Grade

Child's name (Child 4)

School attended

Grade

Medical/Medication

When was your last physical?

Doctor's name

Do you drink alcohol?

If so, how often?

Do you, or have you at any time, used illegal drugs?

If yes, what substance?

How often?

Have you received treatment?

If yes, where?

Approximate first date of use.

Approximate last date of use.

Do you have a disability?

If yes, explain.

Do you have a mental health diagnosis?

If yes, explain.

Are you currently taking any medication?

If so, please list below.

Medication 1

Dosage

Reason for medication

Medication 2

Dosage

Reason for medication

Medication 3

Dosage

Reason for medication

Medication 4

Dosage

Reason for medication

Medication 5

Dosage

Reason for medication

Legal Information

Have you ever been arrested?

Have you ever been charged with a misdemeanor?

Have you ever been charged with a felony?

Have you ever been reported to child protective services at any time?

If yes, explain.

Is anyone in your home on the sex offender registry?

If yes, explain.

Do you currently have a case worker?

If yes, what is their name?

Case worker's phone number

Do you give Miriam's Hope consent to contact your case worker?

Personal History

Mark any of these topics which apply to you currently or have applied to you at any time in the past.

Alcohol abuse Drug abuse Mental health diagnosis Victim of domestic abuse Victim of sexual abuse Victim of emotional abuse Gang affiliation Sexual offender Self-harm Prostitution Homosexual relationship

Faith Steps - Mark which best describes your attitude towards God.

Have you had counseling for any reason?

If yes, explain.

Personal Opinion

What are your reasons for applying to Miriam's Hope? Please include circumstances regarding your current living situation.

List three things you like about yourself.

1.

2.

3.

List three things about yourself that you feel may need improvement/attention.

1.

2.

3.

Independent Living Skills

On a scale of 1-5, how would you rate yourself on your ability to do the following:

Honestly answer as these are ways we identify how we can serve you.

Money management

Food management

Personal appearance

Health

Emergency and Safety skills

Housekeeping

Job seeking skills

Education planning

Interpersonal skills

Legal skills

Job maintenance skills

Transportation

Knowledge of local resources

Leisure activities

Housing knowledge

On a scale of 1-5 how well do you get along with.

Mother

Father

Siblings

Peers

Children

Teachers

Bosses

Co-workers

Police

Landlords

Problem Solving

What do you do when you get angry?

What do you do when you are told what to do by someone in authority?

What are your hobbies?

What are your goals?

What is your dream job?

What makes it difficult for you to find/keep a job?

What is your plan for the next 6 months?

What is your plan for the next 5 years?

If you are accepted, what goals do you wish to accomplish while at Miriam's Hope?

Goal #1

Goal #2

Goal #3

Is there anything else you would like us to know about you before we review your application?

VERY IMPORTANT - MUST READ

Application to live at Miriam's Hope is not acceptance to live at Miriam's Hope. All applications are reviewed by a multitude of counselors to ensure you will be successful. A face to face interview is also required.

I agree to a full background check done by Miriam's Hope.

By typing your name here, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application

For questions call: 402-705-8971

Application Form