Holcomb Behavioral Health Program Survey Request

Holcomb Behavioral Health Systems is pleased to offer the following programs FREE to Delaware County Schools & Community Organizations. Please fill out the following form to request a program. If you wish to have more than one program, please fill out the form again. For additional information, or to schedule a program, please contact Holcomb at 484-444-0412. These programs are coordinated by Holcomb Behavioral Health Systems and funded through the Delaware County Office of Behavioral Health, Division of Drug and Alcohol.

Name of contact person *

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Email of contact person *

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Phone number of contact person *

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Location of requested services (include address) *

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Programs requested *

Positive Action (3rd-5th grade): Positive Action is a 6-lesson program which encourages students to make positive choices. It works by teaching and reinforcing that you feel good about yourself when you do positive actions, and there's a positive way to do everything. Positive Action is designed to improve academic acheievement, school attendance, and problem behaviors.

Keep a Clear Mind (4th-6th grade) KACM is a 5-lesson program that introduces the topics of Alcohol, Tobacco, Marijuana, and Making Good Choices, and the harmful effects and consequences of each substance. Each week, a Prevention Specialist will introduce the weekly topic and students are given a workbook to be completed with a parent or guardian at home. KACM encourages parents and youth to start the discussion of drugs and alcohol prevention together at home. KACM is a great way to increase parent engagement in your school!

We Know BETter (4th-9th grade) We Know BETter is educational programming that includes hands-on, interactive lessons about media influences, the disease of addiction, decision making and refusal skills while also raising your student’s awareness of all forms of addiction including gambling. The program runs four weeks.

Safe Dates (6th-12th grade) Safe Dates is a highly engaging and interactive 6-8 session program designed to stop or prevent the initiation of emotional, physical, or sexual abuse between individuals in a dating relationship. Teens learn to recognize the difference between caring, supportive relationships and controlling, manipulative, or abusive relationships.

Know Limits (9-12th Grade): Know Limits is an engaging and interactive game that increases awareness about issues related to high-risk behaviors including alcohol, tobacco and other drug use and gambling, through activities such as charades, taboo, word scramble and trivia. This is a one-time presentation.

Stall Stories (All Ages): Stall Stories are monthly flyers which highlight environmental campaigns that aim to increase awareness and educate the community on important topics to prevent ATOD use.

Power of Parents (Adults): Research based program developed by MADD (Mothers Against Drunk Driving). The program is a 40 minute presentation that equips all parents, grandparents, and caregivers with the tools needed to help them start the potentially lifesaving conversation about alcohol with their teens.

Speaking Engagements (All Ages): These monthly campaigns aim to break the belief that “everyone is doing it” and educate youth through printed materials, speaking engagements, and activities that, in fact, most youth today are not using drugs or alcohol.

If you requested speaking engagements, please list the topic(s) below

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Preferred Quarter *

Quarter 1 (September-November)

Quarter 2 (December-February)

Quarter 3 (March-May)

Quarter 4 (June-August)

Preferred day(s) of the week for requested program *

Monday

Tuesday

Wednesday

Thursday

Friday

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Grade (s) *

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

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Number of classes/number of students in class *

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