Center for Humanistic Change - Program Request Online Form
Please answer the following questions so CHC can assist you with your program needs.
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Please select the ONE answer that closely matches your location.
School / Facility / Location Name
Location Address - Please include street, city, zip, county)
Name of the person completing this form
Phone Number
Email Address
Organization Contact Name and Title
Organization Contact Phone
Organization Contact Email
Does CHC already provide programming to you/your facility?
Who is your CHC Contact? (If known)
Do you need assistance in identifying or selecting programs to meet your needs?
Clear selection
Do you need assistance planning dates and times?
Clear selection
Choose Programs of interest (select all that apply)
Clear selection
Choose Programs of interest - Multi Session Evidence-Based Programs  (select all that apply)
Choose Programs of interest - Single Session Programs  (* denotes Evidence-Based) (select all that apply)
Small Groups - Life Skills (* denotes Evidence-Based) (select all that apply)
Describe the audience or class: (i.e. grade, age group, youth/parents, seniors, etc.) Include any language barriers to consider or other special needs.
Approximately how many people will be in attendance for the program?
Anticipated date(s) of program? (i.e. school year, semester, month, weeks, summer, or specific event date)
Anticipated length of program? (i.e. day, evening, times, flexible)
Is there any other information you would like CHC to know about your request?   
If you have any questions or need any further information, please contact Stephanie Dorney, Manager of Prevention, Center for Humanistic Change via email to or call 610-443-1595. 
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