The Harbor Home Admissions Application

The Harbor Home Admissions Application

Standard online admissions application. Please complete all questions and signatures; fields are optional unless the PDF marks them required.
Applicant Agreement
Today's Date

MonthDayYear
Date
Personal Information
First Name
Middle Name
Last Name
Age
Date of Birth

MonthDayYear
Date
Social Security Number
City of Birth
State of Birth
Country of Birth
Height
Weight
Nationality
Sex
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address if different from home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Currently Homeless
Identification Possessed
Vehicle Information
Do you own a car?
Car Make
Car Model
Car Year
Current location of Vehicle
Name of Person on Title

First NameMiddle NameLast Name
Emergency Contact Information
Emergency Contact Name

First NameMiddle NameLast Name
Relation
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral & Motivation
How did you hear about The Harbor Home?
Why do you want to come? Be specific
Relationship & Children
Marital Status
Relationship Information (If currently in a relationship, please describe how long you have been together, whether you live together, if the relationship is healthy/supportive, and whether your partner uses drugs or alcohol. Include any children together.)
Children Information (Please list your children’s names, ages, who they currently live with, and where they are living.)
Pregnancy History (Please list the number of pregnancies, including live births, miscarriages, and abortions.)
Family of Origin
Biological Father Name

First NameMiddle NameLast Name
Biological Mother Name

First NameMiddle NameLast Name
Family Relationships (Please describe your relationship with your family — for example: close, distant, strained, broken, or no contact.)
Education
Highest Grade Completed
School Name
GED / High School Diploma

Other
College or Tech School Information
Benefits & Income
State Benefits
Benefit Start Date

MonthDayYear
Date
Benefit End Date

MonthDayYear
Date
Disability Benefits (If you receive disability benefits, please list the monthly amount you receive.)
Do you currently have a bank account? If yes, please list the name of the bank, specify whether it is a checking and/or savings account, and indicate if the account is joint. If it is a joint account, please provide the name of the other account holder.
Legal/Criminal History
Are you currently in custody?
Have you ever been arrested?
Are you currently on probation?
Are you currently on parole?
Do you currently have any warrants?
Are you a defendant or witness in an upcoming case? If so, please provide some information.
Please list any past or current offenses/charges/warrants. For each one, include the charge, a brief explanation of what happened, the current status of the case (pending, dismissed, convicted, etc.), the location where the offense occurred, and the sentence or outcome (if applicable).
Do you have any upcoming court cases? If yes, please include the date and time of each court appearance, the charge(s) involved, and, if applicable, the name and contact information of your attorney.
Please list your probation or parole officer’s information, including their name, office location, phone number, and email address.
Treatment History
Please list any past drug or alcohol treatment programs you have attended. Include the name of each treatment center, the dates you attended, the length of stay, and whether you completed the program.
Have you applied to the Harbor Home before?
Have you ever been a resident at the Harbor Home?
If yes, did you complete the program?
If you did not complete the program, please explain why not.
Please list your primary drug(s) of choice, including the age you began using each substance and the date you last used.
Mental Health
Have you ever been admitted into the psychiatric hospital?
If so, was it voluntary or involuntary?
Have you ever attempted suicide?
Please list all dates of any psychiatric hospitalizations, including the length of each stay and the reason for admission.
Please list all Mental and Health Diagnoses
Please list all medications you are currently taking. Include the name of each medication, how long you have been taking it, and the reason it was prescribed or is being used.
Applicant Agreement Signature
Should be Empty:

The Harbor Home Admissions Application

Applicant Agreement

Personal Information

Vehicle Information

Emergency Contact Information

Referral & Motivation

Relationship & Children

Family of Origin

Education

Benefits & Income

Legal/Criminal History

Treatment History

Mental Health