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Young Adult Intervention Program
We would like to learn more about you and the challenges you're dealing with. Please answer the following questions in as much detail as possible, as we will be using this application as a filter to determine who is the most in need of assistance. If you have any issues with the online form, please feel free to email us at changethefutureTV@gmail.com

We will make an effort to respond to every applicant.
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Your Full Name: *
City, State: *
Phone Number: *
Email Address: *
Your Age: *
What issue or issues do you need help dealing with? *
Please give us a history of this behavior. When did it begin? How has it escalated? What makes you think it's a problem?
Please tell us about your family as a whole. What is your relationship with your parents like? *
What methods have you previously tried to change the behavior? If you've previously sought professional help of any kind, please specify what kind. *
What is your living and employment situation? *
How did you hear about this program? *
Do you have a Facebook or Instagram account? If so, please include a link to your page, so that we might connect.
Is there anything else we should know?
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