Hope House Casper Wyoming

It is recommended that incarcerated applicants apply 6-8 weeks prior to their release date.

Hope House encourages applicants that desire sober living and have not experienced incarceration. Applications will be considered on a case-by-case basis.

We are currently accepting applications for men who desire to live in a sober living, recovery first transitional living community.

Provide a ***REFERRAL LETTER *** from an approved agency (Case Manager, Probation and Parole, Celebrate Recovery, Wyoming Rescue Mission, Therapeutic Community, WSP or another approved agency) Such letter will identify the programs comleted during incarceration, identify strengths and weaknesses, any disciplinary actions, leadership skills, etc.

Read and sign the attached Hope House Rules Policies and Procedures Attachment “A” (ABOVE), and submit this application to Hope House prior to interviewing,

Include a brief Biography telling us about you and why you desire to live at Hope House

Submit PSI or ASI from your case manager, counseling professional or the court. (The application committee will not review incomplete application including missing PSI or ASI).

Upon completion of the application and the above requested documentation we will contact you or your case manager for an interview within 2 weeks of your submission date.

Please fill in the blanks below.

Requested Move-in Date, Estimated release or graduation date if applicable. *

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Personal Information

First Name *

Last Name *

Preferred Pronouns

He, Him His

She, Her, Hers

They, Them, Theirs

Date of Birth *

Phone Number *

Email *

Are you currently incarcerated or in a recovery residence? *

Yes

Current Name and Address

Do you have a current case worker or counselor? *

Yes

Name and contact info of your current case worker or counselor

Are you married?

Yes

Spouse Name

Do you have children?

Yes

How many children do you have?

Do you have legal custody?

Yes

Educational Background: Highest level of school completed

List all schools, certificates, and diplomas

Faith Affiliation/Spirituality

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RECOVERY INFORMATION

Provide a history of any past treatment (substance abuse or recovery or mental health)

Name of Facilities and Treatment Dates

Have you been diagnosed with a substance use disorder?

Yes

provide diagnosis

Drug substance use disorder?

Yes

Drug(s) of Choice

Alcohol substance use disorder?

Yes

Currently or recently in treatment?

Yes

Name/Location of Facility

Did you complete successfully?

Yes

Discharge Date

Do you have a counselor/therapist?

Yes

Name of counselor/therapist

Phone number

May we contact your counselor/case manager?

Yes

Do you have a recovery plan in place?

Yes

Do you attend a recovery meeting?

Yes

group name and location

Do you have a sponsor?

Yes

Sponsor name

Have you ever lived in a residential recovery facility?

Yes

when?

Name and location of facility:

Length of Stay

Did you successfully complete the program?

Yes

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EMPLOYMENT

Are you currently employed?

Yes

Employer

Employer Address

Supervisor Name/Contact Information

Salary

What types of employment skills do you possess?

How long since last employment?

Are you willing/able to get a job in 30 days?

Yes

please explain

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Financial Responsibilities

Are you able to provide the $200 deposit?

Yes

Will someone else be assisting you with rent/deposit?

Yes

Name

Relationship

Address:

Phone

Do you currently have a mandatory savings account?

Yes

what is the balance?

Are you currently required to pay child support?

Yes

required amount

Are you currently behind in child support payments?

Yes

behind amount

Are you currently required to pay any restitution?

Yes

restitution amount

Do you currently have any unpaid fines?

Yes

fines amount

Income

Savings Account?

Yes

savings amount

Social Security?

Yes

social security amount

Disability?

Yes

disability amount

Retirement?

Yes

retirement amount

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LEGAL INFORMATION

List any pending charges/warrants

Have you ever been incarcerated?

Yes

Where, charges and dates

Currently on probation/parole?

Yes

When will you complete probation or probation?

Name of Probation Officer

Location of office

Phone

Are you required to complete community service?

Yes

Are you court ordered to pays fines?

Yes

fines amount

List all felony convictions and dates

Have you ever been charged or convicted as a sex offender?

Yes

Have you ever been convicted of arson?

Yes

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REFERRAL AGENCY

(We require a referral from an approved agency to apply to Hope House.)

Name of referring case manager or agency/organization

Referral name and title

Contact Number

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MEDICAL INFORMATION

Medical Needs: Present medical concerns

List all physical, mental or emotional health issues that concern you including diagnosis.

Are you currently taking medications?

Yes

medications currently taking or should be taking

Do you use tobacco or chew?

Yes

Do you have any type of disability requiring special needs?

Yes

please explain

Do you have any medical restrictions?

Yes

please explain restrictions

Do you have any allergies?

Yes

explain allergies

Do you have any chronic conditions?

Yes

explain chronic conditions

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ALL MEDICATIONS ARE TO BE KEPT SECURED IN A LOCKED SAFE/BOX. RESIDENTS ARE INDIVIDUALLY RESPONSIBLE FOR THE PROVISION OF HIS/HER OWN SAFE/BOX

ADDITIONAL INFORMATION MAY BE DISCUSSED IN INTERVIEW

Hope House also gathers additional data about the applicant to help guide them in addressing the areas that have had an impact on the applicant’s life experiences. This information serves to assist the applicant in developing their recovery plan, vision, and goals for their successful life plan. Applicant will cooperate in providing necessary releases necessary to obtain the information. This information is obtained from the following sources:

CRIMINAL/CIVIL COURT RECORDS (criminal records with a history of violence, weapons and/or sex offender status may disqualify as an applicant. Hope House strongly recommends applicants discuss felonies at the initial meeting.

PRE-SENTENCING INVESTIGATON (PSI)

FAMILY LAW RECORDS

ADDICTION SEVERITY INDEX ASSESSMENT (ASI)

I have read all the material on this application, and answered each question honestly. I have read, understand, and signed the Policies and Procedures as set forth in Attachment “A”. I have a sincere desire to live a wellness-based lifestyle that is clean and sober to achieve stability in the maintenance of the chronic disease of Substance Use Disorder. I have read and agree to the terms and conditions of the attached contract of residency.

Applicant Virtual Signature *

Date *

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Brief Biography

Write a brief biography of your life, where you were born, how you were raised, criminal history and periods of incarceration, your plans for the future and also include your spiritual experiences.

Please include why you desire to be at this Recovery Accountability House and why you would be a good candidate for Hope House.

Biography

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Human?*

Application

We are currently accepting applications for men who desire to live in a sober living, recovery first transitional living community.

Upon completion of the application and the above requested documentation we will contact you or your case manager for an interview within 2 weeks of your submission date.

Personal Information

RECOVERY INFORMATION

EMPLOYMENT

Financial Responsibilities

LEGAL INFORMATION

REFERRAL AGENCY

MEDICAL INFORMATION

ADDITIONAL INFORMATION MAY BE DISCUSSED IN INTERVIEW

Brief Biography

Our Mission Statement

Brochure

Application