Application for Admission


Download as PDF

This application may be submitted here, or printed and faxed, mailed, or emailed to the Harbor of Hope, attn. Tom Pontow or Dan Tearney.

Basic Information

Housing Information

Please provide your current mailing address and contact information.

Counselor/PO Information

Please provide contact information for your counselor or parole officer

Personal Information

Family Information

Medical Information

Education & Employment Information

Employment History

Job 1 - Current or most recent job

Please provide your job title, as well as some description of your duties and experiences in this position.

Employment History, cont.

Please briefly describe any previous employment experience.

Job 2

Please provide your job title, as well as some description of your duties and experiences in this position.

Job 3

Please provide your job title, as well as some description of your duties and experiences in this position.

Additional Documents

If you are a counselor at a prison, jail, or treatment center applying on behalf of a client, please upload the following attachments to submit with the application:

  • Client’s most recent physical
  • Client’s behavior report
  • Personal letter written by the client (outlining current situation and plans for recovery)

If you are not in treatment, jail, or prison and wish to apply for residency, please attach a personal letter to be submitted with the application.

Rules & Rental Agreement

Click the following links to view the House Rules, Client Rules, and Rental Agreement. These links should open in a new tab/window, and you should not lose your place on this form.




I verify that all information provided in this application is true and complete. I understand that any falsification or omission may result in this application being denied from the Harbor of Hope.


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