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Informational Form
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Participant's Name
*
First
Last
Participant's Preferred Pronoun(s)
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Participant's Email
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Participant's Phone Number
*
Participant's Age
*
younger than 11
11 to 13
13 to 14
15 to 16
17 to 18
18+
Participant would like to be contacted via
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Email
Parent / Guardian Name
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First
Last
Parent / Guardian Phone Number
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Parent / Guardian Email
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Parent / Guardian Phone Number
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Parent / Guardian would like to be contacted via
*
Text
Email
Is participant / teen under the care of, or has been under the care of a mental health provider?
*
Yes
No
Planning to work with one
Has the participant / teen been hospitalized for a mental health condition?
*
Yes
No
Your answer to this question does not affect your eligibility to participate in the program.
If answer to above question is yes, please let us know dates and duration of when participant was hospitalized.
Please share anything you’d like facilitators to know in order for us to meet the needs of the participant.
How did you learn about our coaching services / program?
*
CMSC website
Referral from a teen
Referral from a parent
Referral from a healthcare professional
Internet search
Other
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