Informational Form

This form gives us information on the participant and their parent or guardian. We need this in order to hold any coaching session or begin the process of connecting you to the MSC-T Program. If you are uncomfortable providing this information in the form, please let us know by sending an email to Marina at [email protected]. We will identify a way to gather the information that works for you.

Please understand we treat all information provided as confidential. We will never sell your contact information or share it with anyone who is not staff of this program. Lastly, we will only use the contact information you provide to communicate with you.

Participant's Name *

First

Last

Participant's Preferred Pronoun(s) *

Participant's Email *

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 *

• Text
• Email

Parent / Guardian Name *

First

Last

Parent / Guardian Phone Number *

Parent / Guardian Email *

Parent / Guardian Phone Number *

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

Submit