Contact Information:
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Your Name:
(first,last)
*
Street Address:
*
City / State / Zip Code:
*
Phone Number:
(
)
Ext:
*
E-mail Address:
Troubled Teen Information:
Teen's Name:
(first, last)
Physical Description of Teen
*
Sex:
*
Weight:
*
Age:
*
Height:
Click all areas where your teen has problems?
Slight
Mild
Significant
Attitude Problems:
Defiance:
Drug or Alcohol Use:
School Problems/Academics:
Peer Problems:
Emotional Problems:
Psychological Problems:
Physically Violent:
Suicidal:
Does your teen need short or long term treatment?
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Click only one:
1. Short Term:
is for boot camps and out door programs. They tend to be less than 90 day's and are designed to give teens with mild problems a wake up call. Short Term programs may not help teens struggling with significant problems and are designed more for those who have just started down the wrong path.
2. Long Term:
includes Residential Treatment and Specialty Boarding Schools. These programs are designed for teens that need more than a Short Term or Band-Aid effect. It is for teens that need to make Long Term significant changes.
Cost?
(Click on the following that best fits you and your teen)
*
Click only one:
I want information on the best options for my troubled teen, regardless of cost.
I want information on the best options for my troubled teen, balancing cost and quality.
I want information on the best options for my troubled teen, with cost as a primary factor.
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