HHFT Intake Application - CHICAGO DREAM CENTER

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Hope House for Teens

Intake Application

What to Expect from the Hope House for Teens Program

Before beginning the application process, please take a moment to read through the following items on What to Expect from the Hope House for Teens Program

A level of willingness and a desire to change must be present. We are not a lockdown program that desires to keep the children against their will, therefore, the teen must, on some level, want to enter our program. This is something that we will discuss with them, before entry to the program, to ensure that the willingness is present.

We ask that the teens and parents of the teens commit to 12 months of the program. Our program is, at least, one year, anything beyond the 12 months is based on a case-by-case basis.

We do not allow any psychiatric medication here. We believe that Jesus is TRULY our Healer and Deliverer. We have both seen and experienced first-hand the healing power of Jesus and ask that if your teen ends up entering the program, you trust God to do the same in their life.

We have various faith based curriculum. In the time that the boys are with us we have them do various faith based curriculum that we assign to them based on their struggles and needs.

Our schedule is very structured, and we believe that this is very important in the process of healing for the teens. Therefore, we have each day planned out following a schedule. We get up at a certain time, eat at a specific time, have class at a certain time, etc. We help in teaching the teens how to manage their time in a way where they can be at least 5 minutes early to each scheduled event.

We do not allow smoking or other illegal use of ANY substances. While the teens are with us they will need to submit to random drug testing in order to ensure that they are on the right path, abstaining from any and all harmful substances.

HHFT is a communal living setting, therefore all the teens participate in the maintenance of the household. Everyone is assigned a chore, and everyone contributes in the clean-up of meals. The teens are also responsible for maintaining their sleeping space in an orderly manner.

We do not allow the use of cell phones, so after 30 days of being in the program the teens are allowed one 15 minute phone call a week to immediate family only that will be on speakerphone.

Pre-Application Screening

Before being admitted into the program, parents must read through & agree to the following:

* Indicates required field

1. I give permission for HHFT to administer prescription and non-prescription medication to my child as medically required *

Yes No

2. I give permission for HHFT to seek emergency and non-emergency medical care for my child on my behalf (be the power of attorney for health care).This includes routine medical visits, diagnostic evaluations, in-patient and outpatient hospitalizations, etc. *

Yes No

3. I give permission for HHFT to discipline my child in a firm and consistent manner, utilizing individual talks, removal of privileges, or any other non-physical punishment appropriate for his/her developmental level. Spanking or any other forms of physical punishment are not allowed at any time. *

Yes No

4. I give permission for HHFT to communicate with any existing service providers I or my children are involved with to coordinate services. *

Yes No

5. I pledge to use this time to make the necessary changes in order to be in a better position to care for my child. This specifically refers to situations that led me to need for my child to stay at the HHFT. *

Yes No

Hope House for Teens
Intake Application

Basic Information:

Child's Name: *

First

Last

Name of Individual Completing the Form: *

First

Last

[object Object]

Phone Number for Application Follow Up *

Are you receiving support services from other agencies: *

Yes No

Date of Birth: *

Relationship to the Child: *

Email *

If you are receiving support services from other agencies please list along with case worker name and phone number: *

Family:

Please life family members living in the home: *

What is the family's religious preference: *

What is your Childs race/ethnic background: *

Please list the languages spoken in the home: *

Health Background:

Does your child still wet the bed at night: *

Yes No

Has your child had any unusual illnesses or accidents: *

Yes No

If your child has had any unusual illnesses or accidents please describe: *

Please list any current medications (if they are not on any please write N/A): *

Please list any allergies that your child has (if they do not have any please write N/A): *

Does your child have a bedtime routine: *

Yes No

Does you child have any problems associated with bedtime: *

Yes No

If your child does have any problems associated with bedtime, please describe: *

Does your child have any birthmarks: *

Does your child have any hearing or vision issues: *

Is there any history of psychiatric, emotional, or neurological issues in either of the parents family? If yes, please describe and indicate who it is (this includes any issues with addiction): *

If not, please write N/A

Family Doctor: *

Phone Number and Address for Family Doctor: *

What type of appetite does your child have: *

A big appetite - likes to eat a lot A normal appetite A small appetite - you have a hard time getting them to eat

Does your child have a regular diet: *

Yes No

If your child does not have a regular diet, what is irregular about it: *

Has you child had any Illnesses, injuries, hospitalizations, or operations? If yes, please describe and add what age they occurred (If this does not apply, please write N/A): *

Please give copies of records of any hospitalizations if possible

If there are any other problems you child has, that have not been mentioned, please describe (If not, please write N/A): *

Child's Development:

Please describe what your child likes to do for fun: *

Please list any special abilities or skills your child has: *

What situations, relationships, or events tend to be the hardest or most upsetting for your child: *

Please describe current discipline techniques, how often they are needed, as well as how effective they are with your child: *

Social:

Does your child have a nickname: *

What does you child like to do while at home: *

Does your child have any favorite friends or relatives? If so, who: *

What scares your child: *

Discipline/training at our home includes: *

Talking about behavior Rewards/Loss of privileges Spanking Other

If you answered "Other" on the last question, please indicate what other discipline methods you use in your home: *

Education:

School Name: *

School Phone Number: *

School Address: *

Teacher's Name: *

Current Grade: *

Has your child ever failed a grade: *

Yes No

Has your child ever been promoted a grade: *

Yes No

Has your child ever been suspended or expelled from school: *

Yes No

If your child has ever been suspended or expelled from school, please explain: *

Does the child have a 504 plan or an IEP: *

Yes No

Special Education needs: *

Child's Behavior:

Does your child have any current academic or behavior problems? If so, please explain: *

Please check all that apply to your child: *

Depressed Overactive Nightmares Runs Away Anxious Easily Frustrated Sleep Difficulties Wants to die Fearful Peer Problems Eating Difficulties Uses Drugs/Alcohol Withdrawn School Problems Wets the Bed Truant Low Self-Esteem Sexualized Behavior Temper Tantrums Hurts Him/herself Poorly Motivated Touches private parts Plays with Fire Illegal Drugs Daydreams History of Sexual Abuse Destroys Property Steals History of Physical Abuse Aggressive Towards Others Other

If you answered "Other" on the previous question please indicate what other behaviors they demonstrate: *

Please explain those that you checked which apply to your child: *

Parent Information:

Parents or Legal Guardian

*(Please write "N/A" of any of the following questions do not apply)

Father's Name: *

First

Last

[object Object]

Occupation: *

Employer: *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone Number: *

Other Contact Number: *

Mother's Name *

First

Last

Occupation: *

Employer: *

Address (If different from address of the child's father): *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone Number: *

Other Contact Number: *

Marital Status: *

Married Separated Divorced Cohabitation Single Parent

Legal Guardians (If not parents): *

Phone Number of Legal Guardians *

Address of Legal Guardians *

Line 1

Line 2

City

State

Zip Code

Country

In case of emergency, who should be notified first: *

Father Mother Other

If you answered "other" for who should be contacted first in case of emergency, please indicate who you would like to be contacted (include their phone number and relationship to your child): *

Authorized Individuals for Drop-Off and Pick-Up of Child:

The following individuals (other than parents or guardians) are willing to accept responsibility for the child and should be contacted if the parents or guardians cannot be reached.

Name: *

First

Last

[object Object]

Phone Number: *

Relationship: *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Parental Background Information:

What is the reason you are seeking temporary placement of your child(ren) through Hope House for Teens: *

What are the goals that you are looking to achieve in order to be able to bring your child back into a healthy and stable home environment: *

Have you ever been involved with DCFS: *

Yes No

If you have ever been involved with DCFS, please explain (If you answered no, write N/A): *

Have either parents or guardians ever been in drug or alcohol treatment: *

Yes No

If either parents or guardians have ever been in drug or alcohol treatment, please indicate who and explain (If you answered no, write N/A): *

Have you either parents or guardians experienced homelessness: *

Yes No

If either parents or guardians have experienced homelessness in the past, please indicate who and explain (If you answered no, write N/A): *

Have you ever been in need of domestic violence services: *

Yes No

If you have been in need of domestic violence services in the past, please explain (If you answered no, write N/A): *

Have either parents or guardians ever been charged with a crime: *

Yes No

If either parents or guardians have ever been charged with a crime, was there a conviction: *

Yes No

Please describe the circumstances of the charge (If you answered no, write N/A): *

Please list any family members living in the area: *

Please list any close friends or neighbors: *

I have had these experiences (please check all that apply): *

Rape Sexual Abuse Physical Abuse Domestic Violence Homelessness Suicidal Thoughts Victim of Crime Drug Abuse Mental Health Issues Financial Problems Alcohol Abuse None of these apply to me

I struggle with these emotions (please check all that apply): *

Sadness Loneliness Depression Nervousness Fear Anxiety Anger Guilt Emptiness Hopelessness Helplessness None of these

I have filled out this application to the best of my ability and by typing my name on this application, I acknowledge that I have read through all of the relevant program information and that it is my intention for my child to be considered to be temporarily placed in the Hope House for Teens program.

Signature *

Please type your name indicating your signature and agreeing with the statement above.

*After submitting please allow our staff time to look over your application. You can expect a follow-up call within a week of your submission.

Submit

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Chicago Dream Center (CDC) is a registered 501(c)3 charitable non-profit organization.
All gifts are tax-deductible to the fullest extent allowable under the IRS regulations.

Mailing Address
1636 N. California Ave Apt. 2
Chicago, IL 60647
O (773) 799-9023 [email protected]

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