Hey, teen moms! Please contact [email protected] if you have any trouble with this application! We can’t wait to meet you!

Hope House Northern Colorado Direct Assistance Application

The eligibility requirements to apply for our program are:

1. You must be parenting your child
2. You must be between 15 and 20 years old
3. You must be a documented US citizen or have a lawful status
4. You must have a Photo ID or proof of identity and age

Teen Mom Application

Today's Date*
MM slash DD slash YYYY
How did you hear about Hope House?*
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Ethnicity (select all that apply)
- American Indian/Alaskan Native
- Asian
- African American
- White
- Hispanic
- Hawaiian or Pacific Islander
Citizenship Status*
Address*
Street Address Apartment/Suite City State ZIP / Postal Code
Phone*
Email*
Emergency Contact Name*
First Last
Emergency Contact Relationship*
Emergency Contact Phone Number*
How many children do you have?*
Are you currently pregnant?*
Child’s Name*
First Last
Gender
- Female
- Male
Child’s Date of Birth*
MM slash DD slash YYYY
Language(s) spoken in the home
- English
- Spanish
- Other
Do you have a job?
- Yes
- No
What do you do for transportation?
Are you currently on?*
- Probation
- Parole
- Court Supervision
- None of the above
Do you have charges pending?
Is there a warrant for your arrest?
Interests: As Hope House Northern Colorado develops a community program we hope to offer a variety of classes. What might you be interested in at Hope House?
- GED or High School Diploma
- College Help
- Job/Career Help
- Parenting Classes
- Healthy Relationship Classes
- Legal Assistance (i.e. parenting orders, protection orders, etc)
- Budgeting/Finance Classes
- Personal Growth
- Counseling
- Bible Study
- Health & Wellness
- Human Services Assistance (WIC, TANF, Medicaid, Food Benefits, CCCAP, etc)
- Supportive Adult Relationships
- Meeting other Teen Moms through activities
Hope House Northern Colorado is currently fundraising to establish a home for a teen moms in Northern Colorado. We are interested in understanding the residential needs of our teen moms as we prepare to create a home. Are you between the ages of 16 and 20 and would you be interested in or have a need for safe housing for yourself and your child/children?*
Select which items represent a current need for you.
- Food
- Formula
- Diapers
- Wipes
- None of the above
Are there any other things that you would like Hope House to help you out with?