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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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