INQUIRY FORM

In order to assist you, we will need an overview of information. Please fill out our inquiry form below before scheduling your call.

First Name *

Last Name *

Email *

Phone *

State Currently Living *

What is your preferred language? *

APPLICANT

Applicant's Name *

Relationship To Applicant *

Applicant's Gender *

Date Of Birth *

Age *

Current Grade *

Reading Level *

Height *

Weight *

Overview of Behavior *

SELF HARM HISTORY

Applicant is Suicidal? *

Applicant has hurt themself *

Applicant has verbally expressed suicidal thoughts *

Applicant has attempted suicide *

More details about suicide and self-harm

SELF MEDICATION

To what degree does the Applicant use Marijuana *

To what degree does the Applicant use Alcohol *

To what degree does the Applicant use other drugs *

List any other drugs used

More details about self-medication

VIOLENCE

Is the applicant violent with Peers

Is the applicant violent with Siblings

Is the Applicant violent with Property

Is the Applicant violent with Parents/Guardians

Is the Applicant violent with Authority

More Details About Violence

COUNSELLING

Has the Applicant ever been in counselling *

Select all or none that applyDoes the Applicant have any of the following diagnosed? *

List any mental health medication prescribed to the Applicant *

Please give more details about counselling if applicable

SEXUAL ISSUES

Does the Applicant have inappropriate sexual issues? *

Does the Applicant have sexual deviancies? *

More details about sexual issues

HEALTH

Applicant's weight *

How active is the Applicant *

Describe any health issues the Applicant has

OTHER

Does the Applicant have a history of arson?

Does the Applicant any eating disorders?

Is the Applicant's IQ above 85?

TELL US MORE

Share with us, what is the Applicant like when happy? What does the Applicant enjoy? *Include as much detail as you can. This will help us get to know the best possible solution for the Applicant.

My financing options includes *

Time Zone *

Service(s) Interested In *

Having Problems Submitting the Form?

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