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CENTER OF HOPE INTAKE SURVEY FORM
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It is not required for the applicant themselves to complete this
intake survey. Anyone wanting information can complete this
survey for another person. However, if we do a phone interview,
the applicant must be present and willing to come into the program.
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What to know before applying
1. We are a working facility. That means every applicant must be able to physically apply
themselves.
2. We require a six month commitment
3. While we welcome men who are married, we do not allow any man to be in a non-marital
(un married) relationship.
4. Upon entering the program, all clients will enter into a 14 day Orientation Phase. This is to
acclimate them to the procedures and expectation of the program. During this time they are not
allowed to have ANY phone access or any visits. They are only allowed to go off property with a
Center of Hope staff member.
5. All clients at the Center of Hope attend church twice on Sundays (AM-PM) No client may work
ANY job on Sunday.
6. All clients will wake up at 5:30 am Mon-Friday and attend morning devotions at 6am.
7. After the 14 day orientation phase, all clients are expected to seek employment. This program
charges clients a fee of $140.00 per week for housing, bed, and food. We do accept rent
vouchers if you ALREADY have them.
These guidelines are non negotiable and are essential to being considered in candidacy for the
program. If you believe that you (the applicant) or the applicant in which you are applying for
meets these requirements, then please proceed to the application below.
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Applicants Name
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Applicant's Age
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Date of Birth
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Height
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Weight
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Hair Color
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Social Security Number
(Leave blank if unknown)
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Does the applicant have
a current residence?
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YES
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NO
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Please briefly explain the applicants history. If the history is drug related, please list the drugs used
and for how long.
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If drug related, when was the
date of the applicants last use?
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Does the applicant have a
criminal record?
(Be honest, we will check,
checking yes does not
automatically decline them
from the program.)
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YES
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NO
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UNKNOWN
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If "YES" please describe:
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Is the applicant currently on probation?
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YES
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NO
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UNKNOWN
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If "YES" please describe:
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Is the client currently
dating/seeing/involved
with any one?
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Marital Status
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Does the applicant have
an medical conditions?
(Seizures, epilepsy?)
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YES
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NO
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UNKNOWN
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If "YES" please describe:
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Does the applicant have
an mental conditions?
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YES
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NO
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UNKNOWN
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If "YES" please describe:
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Disabilities?
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YES
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NO
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UNKNOWN
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If "YES" please describe:
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Is the applicant currently using
any prescription medication?
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YES
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NO
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UNKNOWN
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WE DO NOT ALLOW ANY PRESCRIPTION NARCOTICS AT
THIS PROGRAM. EXAMPLES INCLUDE, BUT ARE NOT
LIMITED TO: OXYCONTIN, PERCOCET, VALIUM,
TRAZADONE, MORPHINE, THORAZINE, HYDROCODONE,
LORATABS, XANAX, ECT.. IF THE APPLICANT IS
CURRENTLY ON ANY OF THESE MEDICATIONS, HE WILL
NEED TO STOP AND BE COMPLETELY CLEAN FROM THEM
BEFORE COMING INTO THE PROGRAM.
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List all Medication you
are using.
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Does the applicant possess
a valid drivers license?
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YES
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NO
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UNKNOWN
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If "NO" please tell us why:
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Des the applicant have anyone
who will be able to help him with
the fee's associated with the
program?
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YES
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NO
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UNKNOWN
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If "YES" please give the contact
information of the individuals
that can help with the fee's.
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Is the applicant currently paying
child support, alimony,
probation costs, or any other
fees?
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YES
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NO
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UNKNOWN
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If you answered "YES" to ANY
of the above fee's, please give
us the details.
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CONTACT NAME/EMAIL ADDRESS AND
OR PHONE NUMBER (Leave blank if
none)
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By clicking the "submit" button you are agreeing that all the information you provided is correct as
best of your knowledge. You also understand that all applicants will be drug tested upon their
entrance into the program and will not be allowed entry if they have drugs in their system. Each
application is carefully screened and prayed over. If you do not get accepted we are willing to help
you find another place. Please check to ensure all information is correct and click submit. If you do
not hear from us within five days from the date you sent this application in, please contact Adam at
727-729-8399. Thank you and God Bless.
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