Referral Application

Family Information
Parent 1
Relationship:
Full Name:

First NameMiddle InitialLast Name
Primary Phone Number:

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
If deceased, date and cause of death:
mm/dd/yy, cause
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Place of birth:
Parent 2
Relationship:
Full Name:

First NameMiddle InitialLast Name
Primary Phone Number:

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
If deceased, date and cause of death:
mm/dd/yy, cause
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Place of birth:
Applicant's Children
Does she have children?*

YesNo
If yes....
Child 1 Name

First NameLast Name
Date of birth

MonthDayYear
Date
Where is this child at present time?
Child 2 Name

First NameLast Name
Date of birth

MonthDayYear
Date
Where is this child at present time?
Child 3 Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Where is this child at present time?
Child 4 Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Where is this child at present time?

Social Services Information
How many times has the applicant moved in the past 5 years?*
List all residences applicant has had in the past years:
Name of Agency:
Location:
City, State
Reason for residency:
Name of Agency:
Location:
City, State
Reason for residency:
Name of Agency:
Location:
City, State
Reason for residency:
List any agencies that have been involved in serving the applicant during the last five years:

Agencies Involved:

	Name of Agency	City/State	Reason for Involvement
Agency 1
Agency 2
Agency 3
Agency 4
Agency 5

Additional Information about Agency Involvement

Additional Information
What recent events or behaviors brought about your request for placement at this time?*
Please describe the applicant's strengths:*
Briefly state goals of the applicant (For example: goal of improving personal physical health, goal of addressing trauma symptoms, goals of improving relationships, etc.)*
Briefly state why you think this applicant should be accepted into The Harbor Program*
Name of person completing this application:*

First NameLast Name
Relationship to applicant:*

Applicant HerselfLaw EnforcementLegal CounselSocial Worker/Case ManagerCourt OfficialSafe HouseAnti-Trafficking Agency/Task ForceFriend/Family Member
If applicable:
Agency name:
Agency City:
Agency State:
Contact Email:
How long have you known the applicant?*
How did you hear about North Star Initiative and/or The Harbor?*
Signature of Applicant:*

Clear
Signature of Applicant Representative or Referring Agent (if applicant filled in application, please sign again)*

Clear
Four things you should know....
1. A medical and psychiatric examination by a physician will be required as a part of the placement process. Specialized testing may be required based on the needs of the applicant.

2. Financial arrangements, relating to relocation, will be discussed during the application process and finalized at the time of placement.

3. If you need assistance with any part of this application, contact slong@northstarinitiative.org or 717-568-2700 ext 102

4. If this application is not returned within 45 days, we will assume that you chose not to request placement with us.
Please download the PDF file below to help her prepare for her relocation, and her arrival. Further follow up information is located within.
Thank you for applying, she's all set! Welcome to the first day of a new beginning!
Should be Empty:

The Harbor Restoration Program Application

Participant Identification Information

Threat Assessment

Legal Information (if applicable)

Family Information

Parent 1

Parent 2

Applicant's Children

Social Services Information

Medical Information

Education Information:

Additional Information

Four things you should know....

Thank you for applying, she's all set! Welcome to the first day of a new beginning!