Enrollment Form

Youth Name:
Date of Birth
Age:
Sex:	Male Female
Ethnicity	White Hispanic African American Indian
Name of Parents:
Phone:
Address:
Emergency Contact:
Phone:
Support Person/s:
Phone:
Religious Preference:
Home Church Contact Name:
Phone:
School Name:
Phone:
Last Grade Completed:
IEP	Yes No
Please Explain:
What do you feel are youths most important needs? Choose as many as apply.	High School Completion GED Preparation College Application College Funding Job Search Budgeting / Saving Job Training Summer Employment Social Skills Mental Health Counseling Managing Medications D&A Counseling Positive Peer Involvement Appropriate Recreational Activities Life Skills (cooking, laundry) Health
Presenting Problems or Concerns Has youth experienced any of the following behaviors in the past year. Identifying problems enables us to better plan for future success.	Substance Abuse Depression Suicidal Tendencies School Absences Delinquent Behavior Assault Incarcerations Currently on Probation Teen Pregnancy Sexually Inappropriate Behavior
Substance Abuse Type and Frequency:
Suicidal Attempt Dates:
School Absences - Number of days missed in last month and explanation for absences:
Delinquent Behavior Please Explain:
Assaults - List Victims and any Restricted Contacts:
Incarceration Dates:
Probation Restrictions:
Teen Pregnancy - Number of Children:
Sexually Inappropriate Behavior - Explain:
Medical Insurance name (A copy of your medical/dental health insurance if available to youth will be needed):
Card Number:
Primary Physician:
Phone:
Allergies:
Medications (please attach a detailed list to include dosages):

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