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Copyright 2010 HOPE Ministries, Inc.  All rights reserved.
4643 Winbourne Ave., Baton Rouge, LA  70805  225.355.0702
Family Mentoring Program
Self Referral Form
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Name:
E-mail address:
Phone number:
Marital status:
Single (including divorced or widowed)
Married or Partnered
Total number of persons in your household:
Number of children under 18 in your household
(there must be at least one child in your household in
order to qualify for the Family Mentoring Program):
My family is at-risk for homelessness because we...
Check all that apply.
have delinquent rent or mortgage payments.
have received an eviction notice.
are living with friends or relatives who have asked us to leave.
are living in transitional housing.
are living in FEMA housing.
Highest level of education you have achieved:
Less than high school
High school
Some college
Associate's degree
Bachelor's degree
Graduate degree
In most cases, at least one adult in your household must be employed in
order for your family to be eligible for the Family Mentoring Program.
Families whose sole income is SSI or SSDI do not qualify for this program.
If you are not employed but your spouse or partner is, please refer to their
employment for the following questions.
Employer:
Position or Job Title:
Number of months
on the job:
Hourly rate of pay:
Thank you for filling out this self referral form
for HOPE Ministries' Family Mentoring Program.
A representative from HOPE Ministries
will contact you via phone or e-mail
as soon as possible.
Our Mission
Prevent homelessness.
Promote self-sufficiency
and dignity.