Person completing this form:
Applicant Information:
School Name and Grade:
Place of birth:
Date of birth:
Who does applicant currently live with (names/ages of all residing in home)?
Please explain any custody arrangements if applicable.
Please explain the primary problems (behavioral/emotional) that you are seeking assistance with through House of Hope?
Social History:
If so, what age was applicant adopted?
When was applicant informed of being adopted?
Describe any significant family events that have impacted the applicant, including separations or deaths, major illnesses, mental health or substance use issues within the family, or major moves.
Describe applicants relationships with peers does applicant make friends easily, struggle with age appropriate friends or social norms, struggle with healthy romantic relationships, have friends you approve of?
School History:
How is applicant currently doing academically?
Does applicant participate in extracurricular activities? If so, please describe.
Please provide details on any of the following school concerns, if applicable: Truancy, Suspensions, Expulsions, Poor grades, Learning problems or accommodations due to a diagnosis that impacts school success.
Trauma History:
Has applicant ever experienced any traumatic event such as physical, emotional, or sexual abuse, or exposure to domestic violence, or an otherwise violent or life threatening situation? If so, please explain:
Medical History:
Who is the applicants primary care doctor?
Please provide names and contact information of any current treating psychiatrists or therapists please note that these professionals will not be contacted without written consent provided separately by the applicant or guardian.
Does the applicant have any ongoing health problems?
Please list any allergies.
Has the applicant ever been diagnosed with any of the following: ADHD, Bipolar Disorder, Depression, Schizophrenia, Substance Abuse, Post-Traumatic Stress Disorder, Oppositional Defiant Disorder, Any other Psychiatric Disorder?
Has the client ever been hospitalized due to suicidal or homicidal risk?
If yes, please provide information on these events.
Additional Information:
Any additional information you would like for us to know.
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Thanks for submitting an applicaiton. Someone will be in contact with you within 72 hours.
