Hope Harbor Admissions Screening
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Email *
Best Phone Number: *
Screening Questions: *
Yes
No
Unsure
My child is currently suicidal
My child has attempted to kill or seriously harm someone
My child is currently using substances (please include any current alcohol or marijuana usage)
My child is in active withdrawal from substances
My child is experiencing active halucinations, and/or delusions
My child has sexualized behaviors
My child's academic functioning is below the 7th grade level
If your child is a risk of harm to self or others, contact your local mental health services or law enforcement immediately-- do NOT wait to hear back from us. If you answered YES to any of the above your child may need inpatient treatment, or alternative services.
After receiving this form our admissions team will contact you by phone and/or email for more information, including next steps if applicable, within 3 business days. Our phone number is 918-343-0003 and our email address is admissions@hopeharborinc.org.
Youth Name *
Youth's Date of Birth *
MM
/
DD
/
YYYY
Youth Gender *
Home Address (City and State) *
Parent/Guardian Name(s) *
Why are you seeking placement? *
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