Internet Screening Form

In order for your form to be processed and to have a counselor contact you, all fields MUST be completed.  Failure to do so will void your form. All information below must be true to the best of your knowledge. If information is found to be false, it will result in denial of admission, and if child admitted based on falsified information, immediate discharge will result.

Safe Harbor Boys Home Accepts Boys between the ages of 15-17
If your child is not in this age range please see the instructions below
6/29/09 AVAILABLE BED SPACE     ONE
 

Today's Date:
Child's Name:
Child's Age:
Your name:
Relation to Child:
E-Mail Address
Home Phone #
Work Phone #(Type N/A if none)
Alternate Phone #(Type N/A if none)

Your mailing address: city, state and zip code


Who referred you or how did you hear about us?

The required MINIMUM stay is one year.  The cost to Safe Harbor for each student is more than $40,000 per year; that amount includes the residential program; uniforms; the private high school program (Safe Harbor Academy); the vast quantity of vocational education programs and counseling services.  We encourage families to participate in the cost of caring for their son and we have many suggestions as to how that can be accomplished.  Please be prepared to provide financial data to support your need for tuition assistance.  Safe Harbor accepts a students SSI payments.

Who lives in the household with this child? (Choose all that apply)
Mother Father Step-Mother Step-Father
Sister Brother Other relatives Other non-relatives

Does the child use illegal drugs and/or alcohol? 
If yes, please list them 
 

Has this child been arrested? 
If yes, please describe 
 

Has the child seen a counselor, psychologist, psychiatrist
psychotherapist, or other professional help before? 

Has the child been diagnosed  with ADD, ADHD, oppositional defiant
or conduct disorder, or other related behaviors? 

Does the child take prescription medication?
If yes, please specify. 

Has your child attempted suicide?YES  NO

Does your child mutilate themselves? 

What grade is the child currently in? 
Has the child failed any classes? 
If yes, which ones 

Has the child ever run away from home or school? 
If yes, how long was the child gone and where did they go?

Please briefly describe the reason you are considering placement outside the home for this child.

How long has this problem been going on? 

What prompted your action today?

 
 

  Press submit button one time, the application will be transmitted even if a message is not received.  Counselor will contact you via email during normal weekday hours. 

If the child you are seeking placement for is not at least 15 years of age, please email counselor for other resources.  DO NOT use this email address for other requests, as the large volume of inquiries mandates that we provide services to those who follow the instructions.  Thank you for respecting this requirement.