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 *
Last Name *
Date of Birth *
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Ethnicity *
Gender *
Family Information.                                                  
Please share the following information regarding the child or teen's family.
How many immediate family members are in your household? *
Please list names and ages of siblings and any other household members *
How much total combined income did all members of your HOUSEHOLD earn last year? *
Are you or any member of your household currently receiving any of the following: *
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 *
Caregiver's Last Name *
Is the above adult the child/teen's legal guardian? *
If "no", please describe your relationship with the child/teen. *
Home Phone Number (enter "0" if none) *
Mobile Phone Number (enter "0" if  none) *
Email *
Street Address *
City *
State *
County *
Zip/Postal Code *
Emergency Contact First Name (please choose someone who would be locally accessible in case of emergency at the ranch) *
Emergency Contact Last Name *
Emergency Contact Phone *
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 *
Required
Child/Teen currently struggles with: *
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) *
How long has the child/teen been struggling with these issues? *
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 *
Required
Child/Teen Strengths and Character traits (i.e. child is very compassionate) *
How did you hear about Crossfire Ranch? *
Do you identify with a place of worship? If so, where? *
Please list referral agency and person if applicable. *
Child/Teen currently under the care of Therapist/Psychologist (name): *
Please list any current diagnoses *
Does the Child/Teen have any allergies? (environmental, food, medication) Please list all that apply) *
Please describe any physical/mental limitations *
Please describe any past or present assault/aggressive behavior *
Is there any history of animal abuse *
Please share anything you feel would be helpful in understanding the child/teen's situation. *
What other services and/or activities is your child participating in?  *
Please state your name below, indicating that you verify the above information is true and accurate *
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 *
Required
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