Internet Screening Form

In order for your form to be processed, 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.

Safe Harbor Boys Home Accepts Boys between the ages of 15-17
If your child is not in this age range please contact
Florida Association of Christian Child Caring Agencies
NOTICE:  May 5 - May 23 2008, counselor is out of office
and will not be responding to application inquiries
until the week of May 27-May 30, 2008

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?

All residents will be enrolled in Safe Harbor Academy, the high school curriculum program.  The required minimum stay is one year.  The cost to Safe Harbor for each student is more than $20,000 per year.  That figure includes the residential program cost; uniforms; school; 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.

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 only once, the application will be transmitted even if a message is not received.  Counselor will contact you via email during normal weekday hours.  May 5 - May 23 2008, counselor is out of office and will not be responding to application inquiries until the week of May 27-May 30, 2008