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Someone I Know Needs Help
Please fill out the below questionnaire and we will get back to you within 24 hours for assistance.
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* Indicates required question
What is your name?
*
Your answer
How can we contact you?
*
Please provide an email or contact phone number or both.
Your answer
Are you a CBC Provider (please provider agency in next field)
*
Yes
No
Other:
What agency are you with?
Your answer
What is your relationship to the youth?
*
Your answer
What is the youth's name?
*
Your answer
What age range is the youth?
*
Under 10
Between ages 10-13
Between ages 14-17
Over 18
Contact info of youth or legal guardian?
*
Your answer
What is your concern for the youth?
*
Your answer
Has the youth been previously screened for admission to Miami Bridge and denied?
*
Yes
Not to my knowledge
Where is the youth now?
*
At home
Foster placement
Runaway
Locked out
Homeless
Other:
Is the youth prescribed any medication?
*
Yes
No
I don't know
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