Mamma's Hands is dedicated to helping mothers and children get back on their feet by providing longer term shelter, counseling and life skills programs. Mamma's Hands is located in the North Bend area, approximately one hour east of Seattle. Please take a few minutes to complete our Online Future Resident Intake Form and we will contact you shortly.
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General Information

 
Full name *

 
Date of Birth *

 
Phone Number *

 
Please list a VALID Email address. *

Enter "none" if you don't have an email address
 
House of Hope staff will generally try and email you questions about your application or updates on residency. Please check your email on a daily basis after submitting your application.

 
Current address

Include street number/name, city, state and zip code
 
Where are you currently staying? *


 
Please explain your living situation and who you are currently residing with. If you are currently homeless, please be specific as to where you have stayed. *

 
Family members

State name, date of birth, and if they are residing with you
 
How many children do you have residing with you now? *

 
Name - date of birth - relationship

Example: John Smith - 01/01/2010 - son
 
Name - date of birth - relationship

 
Name - date of birth - relationship

 
Name - date of birth - relationship

 
Name - date of birth - relationship

 
Emergency Contact

 
Name - phone number - relationship *

Example: Joan Green - 206-555-5555 - sister
 
What has contributed to your being homeless and needing housing? (select all that apply) *


 
Please explain your situation and how you became homeless. *

 
How long have you been homeless? *

Enter the number of months you have been homeless. Enter a number only.
 
How many times have you been homeless in the past 5 years? *

Enter a number only.
 
Where have you stayed? *

 
House of Hope

 
Have you ever stayed at Mamma's Hands House of Hope? If so, when did you stay here and for how long? Why did you leave House of Hope? *

 
What are some specific ways our program might help you and your family? *

 
List the goals you would like to accomplish during your stay in your first 3 months *

 
List the goals you would like to accomplish during your stay in months 4, 5 and 6 *

 
List the goals you would like to accomplish during your stay in months 7, 8 and 9 *

 
Please tell us about any spiritual and/or religious background you may have. *

 
Do you have a current support system? If so, who is your support system? *

 
Agencies/Programs you are or have been involved with

 
Agency/Contact Person/Contact Phone/Type of Involvement *

 
Agency/Contact Person/Contact Phone/Type of Involvement *

 
Agency/Contact Person/Contact Phone/Type of Involvement *

 
Agency/Contact Person/Contact Phone/Type of Involvement *

 
Agency/Contact Person/Contact Phone/Type of Involvement *

 
Agency/Contact Person/Contact Phone/Type of Involvement *

 
Current Needs *


 
Finances, Employment and Education

 
TANF: Amount and how often you receive these funds. *

 
Food Stamps: Amount and how often you receive these funds. *

 
SSI: Amount and how often you receive these funds. *

 
Employment: Amount and how often you receive these funds. *

 
Child Support: Amount and how often you receive these funds. *

 
Other Income: Amount and how often you receive these funds. *

 
Who do you owe money to? How much do you owe to each? How often do you make payments?

 
Eviction History

 
Amount Owed

 
Are you currently making payments?

     
 
Landlord Name, address *

 
Employment History *

List all employers, positions and dates employed
 
If you are currently unemployed, please explain the reason. *

 
Education

 
What is the highest grade level you reached in school? *

 
Have you participated in any job training programs? If so, please list them. Did you complete them? If so, what is stopping you from working now? *

 
What are your future employment and/or educational plans? *

 
Transportation

 
Do you have a valid driver's license? If so, we will need a copy. *

     
 
Do you have a car? If so, what is the make, model, year and mileage? *

 
Do you have auto insurance? If so, what is the name of your insurance company? *

 
Health

 
In general, how is your health? *

 
Please indicate any conditions that have or may in the future require hospitalization. *

 
Do you have any special medical needs? If so, please explain. *

 
Are you currently pregnant? If so, when is your due date? *

 
Do you have medical insurance/medicaid? *

     
 
Are you currently taking any medications? If so, what type of medications are you taking? *

 
Do you or your children have any communicable diseases? If so, please explain. *

 
Do you smoke? *

     
 
Do you now or have you experienced issues with depression, anxiety or anger? If so, please explain. *

 
Have you ever taken anti-depressants or anti-anxiety medication? If so, please explain. *

 
Have you ever seen or are you currently seeing a therapist or counselor? If so, please provide the name, agency, phone numbers and dates you see him/her. *

 
Children and Family

 
Are you the children's legal guardian? *

     
 
Are your children currently in your care? If not, please explain. *

 
Are the children currently enrolled in school or daycare? *

     
 
If so, please list the school and/or daycare *

 
Have your children ever had emotional or behavioral problems? If so, please explain. *

 
Have any of your children seen or are currently seeing a therapist or counselor? If so, please indicate which child and explain circumstances. *

 
Has CPS ever been involved with your family? If so, please explain. *

 
Do any of your children have any special medical needs? If so, please explain. *

 
Are there any other situations regarding your children that you want to talk about? *

 
What parenting goals or goals for your family do you have for the next year? *

 
Marital History

 
Are you married? *

     
 
Does your family currently have a parenting plan or custody agreement? *

     
 
Have you or has your family experienced domestic violence? *

     
 
Are you still in communication with this person?

     
 
When did you last see him/her?

 
Would he/she try to find you or your children?

     
 
Were weapons involved?

     
 
Does this person have an assault record?

     
 
Did this person abuse your children?

     
 
Do you have a protection order? *

     
 
Name and address of abuser *

 
House of Hope requires that you have no contact with your abuser.

 
Substance Abuse

 
Have you ever had any problems related to drinking alcohol? *

     
 
Have you ever been in an alcohol treatment program? *

     
 
If so, how long have you been in recovery?

 
If the above answer is YES, you may be required to attend a weekly AA meeting and have your attendance verified.

 
Have you ever had any problems related to drug use? *

     
 
What drugs have you used? *

 
Have you ever been in a drug treatment program? If so, how long have you been in recovery? *

 
If the above answer is YES, you may be required to attend a weekly NA or AA meeting and have your attendance verified.

 
Do any of your children have issues with drugs or alcohol? *

     
 
Please explain any issues that you or your children have with drugs/alcohol.

 
Criminal History

 
Have you ever been arrested? *

     
 
If so, why?

 
Have you ever been in jail? *

     
 
If so, why?

 
Do you have a criminal record?

 
Are you on probation? *

     
 
If so, who is your probation officer? Name and contact number. *

 
Do you have any other legal issues? *

 
References

 
Provide the name of 3 people, along with their relationship to you and phone number, who you want to use as references. *

 
By submitting this form, I certify that all information provided is true and correct to the best of my knowledge. I also authorize House of Hope to perform a Washington State Patrol background check.

 
Full name (this serves as your digital signature) *

 
Enter today's date *

 
House of Hope staff will be in contact with you via email. If there is no valid email listed above, the staff will make an effort to call you about your application. If there are openings at House of Hope and you are selected for an interview, House of Hope staff will arrange to meet with you in North Bend. Staff is required to interview a potential resident twice before approving a move-in date. The whole process generally takes around three weeks.

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