954.524.8989 info@houseofhope.org

Intake Screening

Please complete the following screening form in its entirety so that we can best determine what treatment services you require.

Intake Screening Form

Are you currently homeless?(Required)
Are you feeling suicidal?(Required)
Please enter a date and time.
Please describe.
Have you been to detox?(Required)
Have you been diagnosed with a mental illness?(Required)
Are you currently taking medications?(Required)
Are you involved in the criminal justice system?(Required)
Do you currently have medical insurance that can pay for your treatment?(Required)

Application for Admission into Addiction Treatment Program

House of Hope / Stepping Stones
Download this form. This form must be completely filled out or assessment may be delayed. Be sure to ANSWER ALL QUESTIONS.
PDF Application for House of Hope and Stepping Stones

email to: intake@houseofhope.org
or mail to:
908 SW 1st Street
Fort Lauderdale, Florida 33312

© Copyright 2022 House of Hope, all rights reserved.

House of Hope is a 501 (c)(3) non-profit recognized by the IRS. Tax ID Number: 23-7014595
Email: info@houseofhope.org

Solicitation of Contributions Act Disclosure
A copy of the official registration and financial information may be obtained from the Division of Consumer Services by calling toll-free within the state. Registrations does not imply endorsement, approval, or recommendation by the state.
1-800-HELP-FLA (435-7352) www.FloridaConsumerHelp.com

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