Holcomb Behavioral Health Program Survey Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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 or email Allison Doherty at allison.doherty@holcombbhs.org. These programs are coordinated by Holcomb Behavioral Health Systems and funded through the Delaware County Office of Behavioral Health, Division of Drug and Alcohol.

The safety of our staff and your students and faculty is very important to us and we are doing our part to prevent the spread of COVID-19. We are currently available for in person programming but we have developed virtual alternatives to all of our programs if you prefer online learning. If you have websites or online classroom platforms that are approved by your school, please let us know what they are and we will use this information as best as we can.

Name of contact person *

Email of contact person *

Phone number of contact person *

Location of requested services (include address) *

Programs requested *

Positive Action (K- 2nd 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 achievement and school attendance and to decrease problem behaviors. Lesson time for this program must be at least 45 minutes per session.

Keep a Clear Mind (4th-6th grade) KACM is a 4-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!

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

AVOID (6th-12th Grade): The Anti-Vaping Online Information Dissemination (AVOID) Program is a media-based online prevention toolkit for vape prevention for middle and high school students. It is presented in one-hour weekly sessions, for five weeks. AVOID contains brief educational videos and discussion guides. The videos engage students and provide information. The accompanying discussion guides help Prevention Specialists present these videos to youth and conduct a deeper conversation on vaping topics.

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.

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

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

Any day

Required

Grade (s) *

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Required

Number of classes/number of students in class *

Comments

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms