Please complete and submit the questionnaire below and we will call and/or email you to further determine eligibility. The completed questionnaire is confidential and will be reviewed and evaluated by staff only. 

Preliminary Youth Eligibility Questionnaire

Date *
Date
How did you hear about us? *
Name *
Name
Address *
Address
Mobile Phone *
Mobile Phone
Home Phone
Home Phone
• Basic Skills Deficient • Disabled • English is a Second Language (ESL) • Family Violence • Foster Youth • Gang Involved/At Risk • High School Drop-Out • Homeless/Runaway • Individual Education Plan (IEP) • Offender • Pregnant/Parenting