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Mentoring Sessions Participant Application
Crossfire Ranch offers one-on-one and group sessions to kids and teens who are struggling with emotional/social and mental well being due to past trauma, current crisis or other circumstances that challenge their worth, knowing they belong and they have purpose.
Please share the following information regarding the child or teen who is considering participation.
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First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Ethnicity
*
Black or African American
White
Hispanic or Latino
Asian
Native
Pacific Islander
Multiple Race
Other
Gender
*
Choose
Male
Female
Family Information.
Please share the following information regarding the child or teen's family.
How many immediate family members are in your household?
*
Choose
1 member
2 members
3 members
4 members
5 members
6 members
7 members
8 or more members
Please list names and ages of siblings and any other household members
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Your answer
How much total combined income did all members of your HOUSEHOLD earn last year?
*
Choose
less than $14,580
$14,581 -$19,719
$19,720 - $24,860
$24,861 - $29,9999
$30,000 - $35,139
$35,140 - $40,279
$40,280 - $45,4,19
$45,420 - $50, 559
$50,560 - $55, 699
$55,700 - $60,839
60,840 -
Are you or any member of your household currently receiving any of the following:
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Food Stamps
TANIF
SSI
Medicaid
Medicare
Required
Contact Information
Please provide the following contact information for the best adult point of contact for the child or teen.
Caregiver's First Name
*
Your answer
Caregiver's Last Name
*
Your answer
Is the above adult the child/teen's legal guardian?
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Yes
No
If "no", please describe your relationship with the child/teen.
*
Your answer
Home Phone Number (enter "0" if none)
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Your answer
Mobile Phone Number (enter "0" if none)
*
Your answer
Email
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
County
*
Choose
Brown
Calumet
Manitowoc
Outagamie
Shawano
Sheboygan
Waupaca
Winnebago
Other WI County
Out of State
Zip/Postal Code
*
Your answer
Emergency Contact First Name (please choose someone who would be locally accessible in case of emergency at the ranch)
*
Your answer
Emergency Contact Last Name
*
Your answer
Emergency Contact Phone
*
Your answer
Participant Description
This section will help us have a better understanding of how we may best serve the child or teen
Child/Teen has a history of
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ADHD
Adoption
Anger
Anxiety
Bullying
Community Violence
Conflict
Depression
Domestic Violence
Emotional Abuse
Family Divorce
Family Separation
Foster Care
Frequent Relocation
Gangs
Grief
Labor Trafficking
Learning / Cognitive / Disability
Number
Military
Neglect
OCD
ODD
Parental Death
Parental Incaraceration
Parental Substance Abuse
Personal Substance Abuse
Physical Abuse
Physical Limitations/Med Dx
PTSD
School Violence
Self Harm
Sex Trafficking
Sexual Abuse
Suicide Attempts
Suicide Ideation
Suicide Threats
Traumatic Experience
Truancy
Verbal Abuse
Other
Required
Child/Teen currently struggles with:
*
ADHD
Anxiety
Conflict
Depressions
Grief
Learning Disability(s)
Low Self Esteem
OCD
ODD
PTSD
Self Harm
Suicidal Ideation/Threats
Suicide Attempts
Other
Required
Do you feel your child is currently experiencing a crisis/ (for example: isolation, depression, anxiety, missing school or struggles in performing daily functions, suicide ideation or attempts)
*
Yes
No
Not Sure
How long has the child/teen been struggling with these issues?
*
Your answer
Child/Teen Potential Areas of Development
Crossfire Ranch programs are designed to help children grow and develop emotionally, spiritually, physically, relationally.
Please identify the top five (5) outcomes you hope to see in the participant
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Boundaries
Comfort
Communication
Confidence
Empathy
Improved Participation in School/Home Life
Improved Relationships
Improved Self Talk/Feelings
Leadership
Listening Skills
Respect (self/others)
Respite
Responsibility
Self Control
Self Expression
Sense of Belonging
Sense of Purpose
Sense of Safety
Sense of Value/Worth
Social Skills
Trust
Other:
Required
Child/Teen Strengths and Character traits (i.e. child is very compassionate)
*
Your answer
How did you hear about Crossfire Ranch?
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Church
Drove by
Radio
Crossfire Ranch Volunteer/Staff
Internet
Social Media/News
Referral/Partner
Therapist/Counselor
Word of Mouth
Other
Do you identify with a place of worship? If so, where?
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Your answer
Please list referral agency and person if applicable.
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Your answer
Child/Teen currently under the care of Therapist/Psychologist (name):
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Your answer
Please list any current diagnoses
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Your answer
Does the Child/Teen have any allergies? (environmental, food, medication) Please list all that apply)
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Your answer
Please describe any physical/mental limitations
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Your answer
Please describe any past or present assault/aggressive behavior
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Your answer
Is there any history of animal abuse
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Yes
No
Please share anything you feel would be helpful in understanding the child/teen's situation.
*
Your answer
What other services and/or activities is your child participating in?
*
Your answer
Please state your name below, indicating that you verify the above information is true and accurate
*
Your answer
Program Information and Availability
Participants begin Crossfire's program 5 step pathway with weekly 1:1 sessions. After each step, new elements are integrated into the participant's experience - including peer mentorship groups and skill based group sessions.
Please indicate your availability for participation - please list as many as would work that would assure the participant would have transportation
*
Monday Morning
Monday Afternoon
Monday Evening
Tuesday Morning
Tuesday Afternoon
Tuesday Evening
Wednesday Morning
Wednesday Afternoon
Wednesday Evening
Thursday Morning
Thursday Afternoon
Thursday Evening
Friday Morning
Friday Afternoon
Friday Evening
Saturday Morning
Saturday Afternoon
Required
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