Before you start the below application form, please print this Release Form and complete it. You can then upload it to the below application or send it to us via fax or mail.
Do you have a diagnosis? If so, please specify your diagnosis below.
Are you currently taking Medication? If so what medications, and are you taking them as prescribed?
Have you participated in this program before? Yes No
If you answered yes to the above question, please provide reason for leaving the program.
Do you consume any nonprescribed drugs or alcohol? Yes No
By submitting this form, you agree that if the Hope deems a situation to be an emergency that we have your permission to contact your emergency contact listed on these forms.
Hope for Mental Health requests that you grant us permission to discuss your wellness with your medical team. Hope requires this information as we need a confirmed diagnosis to be eligible for this program. In addition to requiring a confirmed diagnosis we need to be able to communicate with your medical team in order to support you completely. We request that all residents complete the Medical Release form.
Name of DCS Worker
DCS Worker Number
DCS Worker Email
Name of Employer
Occupation
Phone Number
Address
Length of Employment
If other sources of Income please explain
On a scale of 1 to 10 please circle where you feel your level of competency is, 1 being no skills at all and 10 being highly proficient.
Release Form Upload
