Applicant Intake Screening Questionnaire

HomeApplicant Intake Screening Questionnaire
  • The Hope House program provides transitional housing and supportive services to women and children for up to 6 months who are experiencing homelessness. The program assist families faced with barriers related to becoming financially stable and obtaining safe and affordable housing. Resident have the ability to make independent decisions within a Personal Goal Plan. This plan provides opportunity for growth and our environment allows Residents to develop educational, physical, and spiritual resources and to establish the financial stability required to move to a more independent level of housing. Our team will carefully review each Applicant Intake Screening Questionnaire. Applicants who meet the criteria will be notified and provided a Hope House Resident Application and Background Check Policy and Acknowledgment form to complete.

    Please Note:
    • The Hope House is NOT AN EMERGENCY PLACEMENT FACILITY. PLEASE CALL 211 for immediate assistance.
      • We will contact qualifying applicants when an opening becomes available. We will provide community resources to the applicant if we do not have openings.
    • Our intake process can take up to 14 days from when the final Hope House Resident Application and Background Check Policy and Acknowledgment is received. Applications cannot be process until the background check information is obtained.
    • Once the Applicant Intake Screening Questionnaire is complete, please submit to the Hope House Foundation. The form can be submitted:
      • In person or mailed to 15604 Northcross Dr, Huntersville, NC 28078.
      • Email: [email protected]
    • If the applicant meets the Hope House programs criteria based on the information provided on the Applicant Intake Screening Questionnaire, the Hope House program staff will notify the applicant and ask the applicant to submit the Hope House Resident Application and Background Check Policy and Acknowledgment. The Hope House program will select the applicant(s) who are determined to exit the Hope House program successfully
    • Only applicants who meet the criteria and completed the Applicant Intake Screening Questionnaire in its entirety will be screened for the next step. If you need assistance completing the form, please contact us at [email protected] or 704-992-1902.
  • Every individual and family situation is unique. However, the following success factors are universal for all of the Hope House program Residents. To be admitted into the Hope House program, you must meet the following criteria. Please read each criteria and select those that are applicable to you.

    1. Highly motivated for success and willing to go above and beyond for long-term change.
    2. Experiencing homelessness, poverty, and unemployment due to a life-altering event.
    3. Unaccompanied single or single mother with children. Male children 10 years can be made under special circumstances.
    4. Free and clean of impairing substances and can always pass a drug test.
    5. Meets background criteria, including willingness for a background check to be conducted
    6. No felonies or sexual offenses
    7. Employed and or demonstrates potential for increased income
    8. Willing to participate in any classes, programs, counseling or assessments identified on your Goal Action Plan
    9. Willing to participate in financial literacy and other program services designed to enhance your understanding of money management
    10. Positive attitude and willingness to give back to the community.
    11. Understand that this is NOT permanent housing and there may be limited living space for your items.
    12. Demonstrate flexibility and adaptability to change
    13. Commit and agree to move out, on or before your specified departure date.
    14. No active restraining order - required for transitional and progress levels of the program.
  • If you meet all the above criteria, please answer the questions below.





  • I hereby affirm that to the best of my knowledge, the above information is true, accurate and complete. I understand that misleading or false statements, misrepresentations, or incomplete information in this questionnaire will be grounds for rejection. I understand that if I am selected for the Hope House program, I will also be offered supportive services that will be provided by qualified staff. I may work with different individuals based on availability or specific skills to address my goals/needs. Services may include, but are not limited to, counseling, assistance in skill building, referral to other providers, and ongoing assessment. To maintain the highest quality of care, staff will communicate with each other about progress through monthly Interdisciplinary Team Meetings (IDT) and via phone and email as needed. Communication outside of the program will be limited as described in the Authorization to Release and Obtain Confidential Information.

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  • All information obtained is confidential and will be used for the application review purpose only. The Hope House program and its affiliates maintain a firm commitment to equal opportunity for all applicants and do not discriminate based on race, sex, age, color, national origin, religion, sexual orientation or disability.