Please list program name, date, and reason for treatment.
Please list three (3) references, their phone numbers and how long you've known them.
By submitting this form, I understand:
• this program is a mentoring/training program and that the staff at finding the family are not counselors. A licensed professional counselor will be available if needed or deemed necessary by staff at finding the family.
• I understand that completing this form does not solidify admittance to finding the family. I understand that this is a screening form to determine eligibility.
• I understand that finding the family requires a health screening at the Health Department upon admittance into the program.