Questionnaire

Youth Town's commitment to helping troubled youth and their families find success spans over 40 years. We have created new programs such as River Quest and Youth Challenge to ensure that each child receives care in the best environment for that child.

Our programs incorporate the most effective approaches for treatment coupled with faith and the Word of God, in order to help troubled youth - and their families - find success that lasts a lifetime.

Youth come to us from many different backgrounds. They are good kids who are in need of HOPE. Often, Youth Town is their last chance.

"Things were easier when he was little. When he had a problem we could sit down and talk about it. Now, I'm at the end of my rope and we can't talk without it being an argument. Time and time again I have tried to get my child who is now a teenager, to do right. But he won't mind, stays out late, and now I'm finding that he is skipping school. Where can I turn before he gets into real trouble?"

Out of respect to you and your child, YouthTown will keep all your information confidential. We only request this information in order to help provide the best guidance possible.

Parent/Guardian Name:

Address:

City:                                               State:                          Zip:   
       
Telephone:                                     Email:
     

Would you like us to call you?
     

Is Your Child male or female?

Child's First Name:


If Other:

Age of Your Child:

Previous Treatment or Placement:

Diagnosis:

Major Issues:

Are You Working With a Referring Professional?

If so, who?