"Where Hope Finds a Home"
Thank you for your interest in Isabel Hope Harbor.
This form is a Placement Pre-Screening Request and is not a housing application.
Isabel Hope Harbor is a private structured transitional living program for adult men (21+) who are committed to living in a safe, sober, and accountable environment while working toward greater stability and independence.
We are not a treatment facility, detox center, emergency shelter, or state-operated halfway house.
Applicants who appear to meet our initial eligibility requirements will be contacted to complete a brief verbal screening.
Estimated Completion Time: 5-7 minutes
Please answer each question as accurately as possible.
Your responses help us determine whether Isabel Hope Harbor is an appropriate fit for your needs and whether to move forward with a verbal screening.
⭐ SECTION 1 — Contact Information
Full Name
Client first nameClient last name
Phone Number (Required)
Client phone
Email Address
Client email
Preferred Contact Method (Required)
Emergency Contact Name: Text field
Relationship: Text field
Emergency Contact Phone Number: Phone field
⭐ SECTION 2 — Initial Eligibility
Are you a male who is at least 21 years old? (Required)
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Are you currently clinically stable and not in need of detox, inpatient treatment, or medical supervision? (Required)
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Do you currently have any contagious illness that would prevent you from safely living in a shared residential environment?
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If yes: Text field
Do you currently take any prescribed medications?
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Are you able to independently store, take, and manage your prescribed medications without staff assistance?
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Are you currently abstaining from alcohol and illegal drug use? (Required)
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Are you willing to maintain a drug- and alcohol-free lifestyle while living at Isabel Hope Harbor? (Required)
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Are you willing to follow house rules, participate in a structured program, and share a bedroom if assigned? (Required)
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Are you currently under any form of criminal justice supervision? (Required)
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If you are under supervision, do you have any conditions that would affect your ability to participate in the program (such as travel restrictions, curfew, or required reporting)?
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If Yes: Text field
Are you required to register as a sex offender? (Required)
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Isabel Hope Harbor is not an ADA-accessible residence. Are you able to safely navigate stairs and the home's physical environment without ADA accommodations? (Required)
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⭐ SECTION 3 — Recovery & Program Readiness
Approximately how long have you been continuously sober? (Required)
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What is the longest period of continuous sobriety you have maintained? (Required)
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Are you currently participating in recovery support? (Required)
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If Yes, select all that apply:
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Other: Text field
What is your primary goal for coming to Isabel Hope Harbor? (Required)
Select all that apply:
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○ Other: Text field
⭐ SECTION 4 — Housing & Financial Readiness
Where are you currently staying? (Required)
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○ Other:Text field
Desired Move-In Date (Required)
Date
What will be your primary funding source for the monthly program fee? (Required)
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○ Other: Text field
Approximate Monthly Income (Before Deductions) (Required)
$Text field
⭐ SECTION 5 — Program Requirements
Do you currently have a valid government-issued photo ID? (Required)
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If No:
Which best describes your situation?
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Do you currently have a working cell phone with active voice and text service? (Required)
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If No:
If accepted, when could you obtain one?
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Do you have access to a smartphone capable of downloading the One Step app? (Required)
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Primary Transportation (Required)
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⭐ SECTION 6 — Referral Information
How did you hear about Isabel Hope Harbor? (Required)
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There: Text field
If referred by a professional or organization, please provide their name and organization:
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SECTION 7 — Program Understanding
Please review and acknowledge each statement.
Checkboxes I understand the monthly program fee is $800.
CheckboxesI understand there is a $200 non-refundable move-in fee due prior to move-in unless otherwise approved.
Checkboxes I understand this is a placement pre-screening request and does not guarantee admission.
CheckboxesI understand admission is based on eligibility, program fit, successful completion of the screening process, and bed availability.
Checkboxes I understand Isabel Hope Harbor is a private structured transitional living program and is not a treatment facility, detox center, emergency shelter, or state-operated halfway house.
CheckboxesI understand residents are expected to maintain a drug- and alcohol-free lifestyle.
CheckboxesI understand random drug and alcohol screenings may be conducted during my residency.
CheckboxesI understand a positive drug or alcohol test, refusal to test, or tampering with a screening may result in corrective action or discharge in accordance with program policies.
CheckboxesI understand Isabel Hope Harbor is not an ADA-accessible residence.
Checkboxes I understand smoking and vaping are prohibited inside the residence.
CheckboxesI understand overnight guests and personal visitors are not permitted.
CheckboxesI understand residents are required to maintain a working cell phone with active voice and text service and actively use the OneStep platform during residency.
CheckboxesI understand participation in required house meetings, assigned responsibilities, and program expectations is required.
CheckboxesI have reviewed, or agree to review, the Isabel Hope Harbor website and virtual tour before my verbal screening.
⭐ SECTION 7 — Optional Notes
Anything else you would like us to know?
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⭐ SECTION 8 — Applicant Certification & Signature
Please read the following statement carefully.
I certify that the information I have provided is true and complete to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in my placement pre-screening request being denied or, if admitted, may result in corrective action or discharge from the program.
I understand that submitting this pre-screening request does not guarantee admission into Isabel Hope Harbor.
Client first nameClient last name
Signature
Date
CheckboxesBy signing below, I certify that the information provided is accurate and authorize Isabel Hope Harbor to use this information to determine my eligibility for further screening.
Privacy Notice: The information collected on this form will be used solely to determine initial program eligibility and to contact you regarding your placement request. Information will be maintained in accordance with Isabel Hope Harbor's privacy and record retention practices.