Need Help? We provide direct care for families and teens in crisis. Please fill out this form for help. Requesting for? Requesting for? Myself Youth in my charge Your Name Your Email Address City Zip Code Your Phone # If you don't answer can we leave a message? If you don't answer can we leave a message? Yes No Reason for requesting services? Their Name Your relationship with the person? Their School and Grade Their Date of Birth (??/??/????) Are they male or female? Are they male or female? Male Female Are they a runaway? Are they a runaway? Yes No Have they threatened to runaway? Have they threatened to runaway? Yes No Have they runaway in the past? Have they runaway in the past? Yes No Number of times they have runaway? Do they have attendance issues? Do they have attendance issues? Yes No Have they skipped class? Have they skipped class? Yes No Have they been adjudicated? Have they been adjudicated? Yes No Name of Probation Officer? Have you or family member threatened suicide? Have you or family member threatened suicide? Yes No Have you or your family member attempted suicide? Have you or your family member attempted suicide? Yes No Number of times suicide was attempted? 8 + 10 = Submit