Black Boy Peace Support (Ages 10-19)

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Support Intake

This section is designed to assess your overall well-being and connect you with resources that align with your needs. By sharing your experiences, challenges, and goals, we aim to provide access to mentorship, wellness resources, and mind-body health practices tailored to Black males aged 10-19.

Learn more about Black Boys OM here : https://blackboysom.org

You will have the opportunity to:
✅ Reflect on your emotional well-being, support systems, and experiences
✅ Access journaling tools and self-care resources designed by and for Black men
✅ Connect with certified Black Male wellness practitioners in your area
✅ Explore free mind-body-spirit health resources, including yoga, meditation, and stress management
✅ Learn about opportunities in yoga teacher training and personal development through our Black Boys OM School of Yoga

Your responses will help us better understand how we can support your journey toward well-being practice and remembrance and reclamation of your innate wholeness.

Email *

Name:

Age:

Date of Birth:

Contact Information:

Guardian's Name and Contact Information

Cultural and Community Background:

Ethnic Identity: How do you identify yourself culturally or ethnically?

Community Involvement: Are you or your family involved in any cultural, religious, or community groups? If so, please describe.

Health and Wellness History:

Physical Health: Do you have any current health conditions or concerns?

Mental Health: Have you or your family members experienced counseling or mental health support before? If so, what was the experience like?

Mind-Body Practices: Have you engaged in practices like yoga, meditation, or mindfulness? If yes, please elaborate.

Current Challenges and Goals:

Emotional Well-being: How have you been feeling emotionally recently?

Stress Factors: Are there specific situations causing you stress or anxiety?

Goals: What do you hope to achieve through engaging with our resources and offerings?

Support Systems:

Family Dynamics: Who do you consider as part of your family?

Community Support: Are there individuals or groups you turn to for support?

Cultural Practices and Beliefs:

Traditions: Are there specific cultural traditions or practices you observe?

Spirituality: Do you engage in any spiritual or religious activities?

Barriers to Wellness:

Access to Resources: Have you faced challenges in accessing wellness or mental health resources?

Perceptions of Wellness Practices: How do you and your family view practices like yoga and meditation?

Can you describe any experiences where you felt treated unfairly because of who you are?

What are some activities that bring you joy and help you relax?

How do you cope with stressful situations?

Are there personal, cultural or family practices that support your well-being?

Connection with Local Practitioners:

Would you like to be connected with a certified Black Male, mind-body health practitioner in your area for personalized support? (Please note: Sessions are privately arranged between families and practitioners.)

Partnerships and Further Opportunities

Youth-Centered Partner Organizations Information on organizations focusing on Black youth empowerment will be sent to the email listed on this form.

Enhance your wellness journey with our Yoga Teacher Training program. Deepen your practice and gain accreditation to share yoga with others.

Learn more at Black Boys OM Yoga Teacher Training