Online Application

Requirements for Eligibility:

Before filling out the online application, please read the list of requirements below. If you are ineligible for our program, please call our office for a referral to an organization that can help you.

21 Years of age or an emancipated adult aged 18 or over with custody of a minor child
Able to live independently. (DOHTM does not provide medical supervision or assistance)
Single or married (only married couples will be allowed to reside together)
Lafayette County resident for a minimum of one year, or a non-resident who has worked (and is currently employed) in Lafayette County for more than 6 months.
Applicants must work. (Able and willing to hold a job)
No arresting history of crimes involving sex, children, or violence
Must be in need of resources
Must be drug-free and pass a background check to be admitted to the program. (There is NO illegal drug or alcohol use allowed during the program)
Must remain drug and alcohol-free for the full time of the program

Doors of Hope ONLY serves families with minor children in the home. Do you have legal custody of minor children? *

*IF YOU DO NOT HAVE MINOR CHILDREN IN THE HOME, PLEASE DISCONTINUE THE ONLINE APPLICATION. CALL 662-234-1100 FOR A REFERRAL TO AN ORGANIZATION THAT CAN HELP YOU.

How long have you lived in Lafayette County? *

Under 6 months
6 months to 1 year
Over 1 year
I do not live in Lafayette County, but I am currently employed in Lafayette County (must be employed in Lafayette county for more than 6 months)
I do not live or work in Lafayette County***

*** IF YOU DO NOT LIVE OR WORK IN LAFAYETTE COUNTY, PLEASE DISCONTINUE THE ONLINE APPLICATION. CALL 662-234-1100 FOR A REFFERAL TO AN ORGANIZATION THAT CAN HELP YOU.

What caused your current situation? (Provide as many details as possible!) *

Applicant Name *

First

Middle

Last

Date of Birth *

Sex *

Male
Female

Please Check your race and ethnicity. If bi-racial or multi-racial please check all that apply.

Applicant's Phone Number: *

Applicant's Email *

Current Address (or address of person you are staying with) *

Drivers License/State ID Number (please include the state your ID was issued in) *

Marital Status *

If married, describe your relationship with your spouse. *

List all children in your household (full names & ages): *

Are there other children that are not in the household? *

If there are other children that are not in the household, please tell us why and who has custody (be specific for each child): *

Do you have family in Lafayette County? If so, please list their relationship with you (ex: Mom, Dad, Grandmother, Uncle, etc.) *

Emergency Contact #1 *

First

Last

Phone Number *

Emergency Contact #2 *

First

Last

Phone Number *

Select your highest level of education: *

School *

Year Graduated *

What is your total household income? This includes all income frome veryone in the household (including social security, child support, and paychecks).

Are you currently employed? *

Have you ever been fired? *

1. Employment History *

Job Title *

Rate of Pay *

Reason for leaving? *

2. Employment History *

Job Title *

Rate of Pay *

Reason for leaving? *

3. Employment History *

Job Title *

Rate of Pay *

Reason for leaving? *

4. Employment History *

Job Title *

Rate of Pay *

Reason for Leaving? *

Have you applied for TANF? *

Have you ever received workman's comp benefits? *

Have you signed up with the WIN Job Center? *

Do you have open child support cases? *

If you do have open child support cases, please list which child/children they apply to.

Have you applied for disability? *

Is anyone in the family on Medicaid? *

Is anyone in the family on Medicare? *

Does anyone in the family have health insurance? *

Please list any family members on Medicaid, Medicare, or who have other forms of health insurance. *

Are you a veteran? *

If you are a veteran, please list which branch and when you served.

Please list any present or outstanding debts/collections/judgements. *

Format this section by listing the item, lender, and amount due for each debt.

Does anyone in the household have posession of a vehicle? *

Clear title? *

Make and model of vehicle:

Year

License Plate #:

Are your tags current? *

Do you have liability insurance? *

Do you have car seats as needed for children? *

Do you have any outstanding tickets, fines, or violations? *

If you have had any outstanding tickets or fines, please provide details (amount, location, date received, community service performed, etc.)

Have you ever been arrested? *

Please note that a criminal record will not immediately disqualify you from our program.

Have you ever had a child protective case filed against you? *

Are you involved in a current child protective case? *

List ALL of your arrests. (If you do not have an arrest record, please type N/A) Failure to provide this information may void application. *

List arrests by date, charge, sentence, time served, and where time was served.

Last release date:

Prison Unit:

County of Offense:

Are there any warrants out for your arrest? *

Yes
No
Unknown

Are there any restraining orders against you? *

Does anyone in your household have a history of drug and alcohol abuse? *

If yes, please indicate which household member, when the last use of drugs/alcohol was, and how much.

Please list any and all medical problems. *

Doors of Hope does not provide any medical or behavioral health benefits or treatment.

Are you presently using any prescription drug(s) for any condition listed above?

Do you smoke? *

If you do smoke or use tobacco products, how much?

Are you or your spouse currently pregnant? *

If yes, when is the due date?

Is the pregnant individual currently receiving prenatal care through a medical professional?

Has anyone in your household been treated for a mental/emotional condition? *

Is this person currently using prescription drugs to treat this condition? *

If someone in the household has ever been treated for a mental/emotional condition, please describe the treatment plan. This includes the diagnosis, counseling services, where the counseling services take place, and the names of both their cousnelor and doctor. *

Have you ever lived in public housing? *

have you ever been banned from or denied public housing? *

If you have been banned or denied public housing, please tell us from where and why.

This is the beginning of the MONTLY EXPENSES section. Please list any other sources of income/benefits, including TANF, Food Stamps/SNAP, Child Support, SS/SSI/SSDI, Veteran's Benefits, Unemployment, Worker's Comp, Checking Account, Savings Account, & other assets/income. (If none, type N/A) In the following smaller boxes, please list your monthly expenses for utilities, rent, food, etc. *

Utilities (Electricity, Gas, Water, Internet, etc.) *