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2. Full Legal Name*
3. Date of Birth*
   Date of Birth
5. Age*
7. Your Email Address
8. Parent's Email*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Home Phone Number*
17. Cell Phone Number
19. Who do you live with?*
20. Relationship*
22. Mother's Full name
23. Mother's date of birth
    Mother's date of birth
25. Is she living?

    1. Yes
    2. No
27. Mother's address if different than yours
29. City
30. State
31. Zip Code
33. Mother's employer
34. Mother's work phone
36. Father's full name
37. Father's date of birth
    Father's date of birth
39. Is he living?

    1. Yes
    2. No
41. Father's address if different than yours
43. City
44. State
45. Zip Code
47. Father's employer
48. Father's work phone
50. Are your parents:*

    1. Married
    2. Single
    3. Divorced
    4. Not Married
    5. Re-Married
51. Are your parents residing together?*

    1. Yes
    2. No
53. If not, do they share custody?

    1. Yes
    2. No
54. Are either of your parents incarcerated at this time?*

    1. Yes (Mother)
    2. Yes (Father)
    3. Yes (Mother and Father)
    4. No
56. If yes, where are they incarcerated?
58. Name of School*
59. Current Grade:*

    1. Middle School Grade 6
    2. Middle School Grade 7
    3. Middle School Grade 8
    4. Middle School Grade 9
    5. High School Grade 10
    6. High School Grade 11
    7. High School Grade 12
61. Counselor Name*
62. Do you have an IEP or 504?
64. Are you currently expelled?*

    1. Yes
    2. No
65. Have you ever been expelled in the past?*

    1. Yes
    2. No
67. If yes, please provide dates and reason for expulsion
69. Date
    Date
70. Reason
72. Date
    Date
73. Reason
75. Date
    Date
76. Reason
78. Date
    Date
79. Reason
81. Date
    Date
82. Reason
84. Employer
85. Employer Phone Number
87. Employer Address
89. City
90. State
91. Zip Code
93. Hours per week
94. Are you currently or have you ever been in therapy, counseling or court ordered treatment?*

    1. Yes
    2. No
96. If yes, what for?
98. Name of Therapist
99. Phone of Therapist
103. Are you taking any medication?*

     1. Yes
     2. No
105. If yes, what are you taking and what is the reason?
107. Medication
108. Reason
110. Medication
111. Reason
113. Medication
114. Reason
116. Medication
117. Reason
119. Medication
120. Reason
122. Name of therapist
123. Therapist phone number
125. Have you ever had involvement with Social Services?*

     1. Yes
     2. No
127. If yes, when and for what reason?
129. When
130. Reason
132. When
133. Reason
135. When
136. Reason
138. When
139. Reason
141. When
142. Reason
144. Do you have any charges pending in this or any other court?*

     1. Yes
     2. No
146. If yes, please provide the charge and jurisdiction:
148. Charge
149. Jurisdiction
151. Charge
152. Jurisdiction
154. Charge
155. Jurisdiction
157. Charge
158. Jurisdiction
160. Charge
161. Jurisdiction
163. Are you on probation / parole / diversion in any other jurisdiction?*

     1. Yes
     2. No
165. If yes, please provide the charge and jurisdiction:
167. Charge
168. Jurisdiction
170. Charge
171. Jurisdiction
173. Charge
174. Jurisdiction
176. Charge
177. Jurisdiction
179. Charge
180. Jurisdiction
182. Name of probation / parole officer
183. Probation officer phone number
185. Criminal History, including any juvenile offenses, arrests, deferred judgments, and dismissals:
187. Charge
188. Jurisdiction
189. Date
     Date
191. Charge
192. Jurisdiction
193. Date
     Date
195. Charge
196. Jurisdiction
197. Date
     Date
199. Charge
200. Jurisdiction
201. Date
     Date
203. Charge
204. Jurisdiction
205. Date
     Date
207. Today's Date*
     Today's Date
208. Signature (Your Name)*
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210. 1. Receive an email copy of this form.
211. Email address

     This field is not part of the form submission.

212. Submit

* indicates a required field