Phoenix Gang Intervention and Prevention
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Phone Consultation Form

We work closely with most of our clients to tailor our programs to best address their needs. We can help you design an entire new program, or complement your existing program elements. Your response to the form below will enable our staff to discuss the most appropriate program options and program resouces with you. There is no additional charge for this service.

So that we may better serve you, please fill out the form below as completely as possible.

Your name: 
Your e-mail: 
Your organization: 
Your phone number: 
URL of your organization's web site: 
Your position: 
Address, line 1: 
Address, line 2: 
City: 
State/Province: 
ZIP code: 

I prefer you reach me

Population/Cultural Emphasis of Your Program (check all that apply)
Males
Females
Spanish-Speaking
English-Speaking
Juvenile/Youth
Lower functioning clients
Caucasian
Native American
African American
Hispanic
Gang Members
Other (explain)
Issues faced by clientele (check all that apply):
Violence/Aggression
Substance Abuse/Chemical Dependency
Behavioral Health Issues
Homelessness
Dual Diagnosis
HIV/AIDS
What setting(s) does your organization operate in? (check all that apply)
Correctional
Drug Court/Diversion
Schools
Schools
Community Group
Juveniles
Faith-based
What approach(es) does your organization prefer?
Cognitive-Behavioral Therapy (CBT)
Motivational Interviewing (MI/MET)
Relapse Prevention
Risk-Factors/Protective Factors
Developmental Assets/Strength Buildings
Behavioral Health Emphasis
Social Learning Model
Coping Skills for Self-Efficacy
Cognitive Restructuring
Dual Diagnosis Emphasis
Substance Abuse Emphasis
Integrated/Combined Approach
Other Information
to — Age range of clients
— Average age of client
— Hours of classroom time available each week
— Hours of counseling classrooms available
— Hours of other activities

What kind of facility do you have?

Where did you hear about us?

Questions/Comments (feel free to enter special needs):


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