Please let us help you through the application process by filling out the following information completely. You can continue on and fill out the application by downloading the .pdf files or you can have us send you an application by mail.

Our participants must be referred by individuals or agencies with the authority to refer the youth and the resources to pay for participation.


    School-basedCounty/DJJCounty/DFCS



    YesNo

    Referral Source Information









    PhoneEmailText Message


    YesNo

    Client Information Section








    Biological Parent Information



    MedicaidAmerigroupWellcareCenpaticoCareSourceOther




    YesNo


    Please provide a list of past schools enrolled starting with middle school and ending at high school if applicable:





    YesNo


    GEDHS Diploma



    YesNo

    Mental Health Diagnosis


    Parent/Guardian Information Section







    Legal Section


    YesNoUnknown


    ProbationNot on Probation




    YesNo