North Star Initiative
Residential Program

Admission Application

Please note: We are not an emergency service. If you are in need of emergency placement, please contact 911 or the human trafficking hotline at 1(88) 373-7888.

Program Restrictions
Please know that North Star is resourced to provide services for a participant who meets the following criteria:

• Is between the ages of 18-35 at the time of applying
• Has been clean and sober at least 30 days (at the time of intake)
• Does not have dependent children who require placement
• Is ambulatory
• Is biologically female
• Is not prescribed methadone
• Is able to self-manage

If all of the above are true of the applicant, we look forward to learning more through this application.

This form assists NSI staff in determining whether we are the best fit for an applicant to participate in our residential program. We ask that all information be completed in a concise, thorough manner. The application will be reviewed by the multi-disciplinary team before making any determination of acceptance into the program.

Completion of this application assumes the participant consents to allow the Referring Agency to provide this information in consideration for her acceptance to the Restoration Program.  We do not discriminate based on the responses provided on this form.  Your candid, factual, and complete responses assist us in proceeding with the referral process.

ALL INFORMATION WILL BE KEPT CONFIDENTIAL

If applicable:

If "Yes" to any of the above, name of the court service worker or probation officer and list Offense:

Other Information:

If yes....

List the three most recent residences the applicant has had:

List any agencies that have been involved in serving the applicant during the last five years:

 Thank you for applying!

If you need assistance with any part of this application, contact myoung@northstarinitiative.org or 717-268-9124 

 

You can anticipate a response from our team within 24 hours on the status of your applicant upon submission.