Center Based Screener For Youth

If you are in a state of crisis or need immediate help for any reason, please pause filling out this form and call 911. If you feel that you are a danger to yourself, please contact the National Suicide Prevention lifeline at 1-800-273-8255

Center Based Screener

PREREQUISITE FOR PROGRAM ADMISSION: Youth MUST meet the following for the group intervention to be impactful.

Click yes or no to questions below.
Youth is able to refrain from physical aggression, vocal outbursts, and property destruction when experiencing strong emotions or difference in opinion from others.(Required)
Youth is able to participate in a classroom style workshop for a period of 60 minutes.(Required)
Youth is able to communicate wants and needs to peer(s) and group facilitators in an appropriate manner.(Required)
Has youth struggled with substance abuse in the last 30 days?(Required)
What is your youth currently struggling with? (Select all that apply)(Required)
In the last 30 days what were your youth's top 3 stressors?(Required)
Has your youth received any type of therapy?
Has your youth been hospitalized for any reason in the last 30 days?

Parent Contact Information

MM slash DD slash YYYY

Youth Contact Information



This is not a guarantee of services. This form is utilized as an initial screening process for staff purposes only. If it is determined that your youth may be a potential fit for this program, a member of our staff will reach out to you.