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CHADS Mentoring and Counseling Interest Form
Please fill out all fields below and a CHADS staff member will be in touch with you shortly regarding our one on one services.
***Please note that this form is not intended for emergency or crisis situations. If you are experiencing an emergency please call 911 or the Suicide Prevention Lifeline at 988***
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Name
Your answer
Email
Your answer
Phone
Your answer
What is the best way to contact you?
Phone
Email
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What time of day is best to contact you?
Your answer
Please select which service(s) you're interested in for your child (you may select all that apply):
*
One on One Social Emotional Mentoring (non-therapeutic) focused on self-regulation, relationship building, etc.
Individual or group counseling services focused on anxiety, depression, and suicide (brief, strengths-based, solution, focused)
Other:
Required
What is your child's age?
Your answer
What school does your child attend?
Your answer
What days/times is your child available to meet with a CHADS staff member?
Your answer
Is there any other information you would like us to know before a CHADS staff member reaches out to you?
Your answer
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