helping families with the troubled teens all across the nation...

Help Request Form

Please provide the contact information and brief description of your situation. We collect this data to establish the initial contact. All further communication will be done with the real person - experienced staff member committed to help your family with the problem you are going through. Ask your questions, there is no risk and no obligations to it.

Parent/Guardian
First Name:
Last Name:
Email:
Home Phone:
Work Phone:
Street Address:
City:
State:
Zip Code:

Child

First Name:

Last Name:

Sex:

Male Female

Age:

Please check all boxes that apply to your child:
Lying and manipulation Disrespectful to adults Drug and/or alcohol abuse Sexually active Lack of self esteem Poor behavior and choices Decline in grades	Poor choices in friends Angry or violent behavior Cutting Suicidal Runaway ADD/ADHD/ODD Bi-polar

Describe your situation and concerns
If these patterns of behavior continue where do you see your child in one year?

Do you feel that immediate action is needed to correct your child's behavior? Yes No
Are there any other children in your home being affected by this child's influence? Yes No
Other Comments

Financial Grant Application
Children in home:
Annual Household Income:

All form fields with the captions in bold are required.

Your information is safe with us. We will only use it in matters related to your request.

Thanks to our generous donors the limited number of financial grants is now available.

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