First Name
Last Name
Phone
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Participant Name
Participant Age
Gender of Participant—Please choose an option—MaleFemale
How did you find our site?—Please choose an option—Word of MouthAlumniEducation ConsultantMental Health ProfessionalSearch EngineOther
If other, please specify
In what country do you reside?—Please choose an option—United StatesCanadaMexicoUnited KingdomAustralia---------------AlbaniaAlgeriaAmerican SamoaAngolaAnguillaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia HerzegovinaBotswanaBrazilBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsChadChileChinaColombiaCongoCook IslandsCosta RicaCroatiaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEstoniaEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGrenadaGuadeloupeGuamGuatemalaGuineaGuinea BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIreland (Republic of)IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKosrae IslandKuwaitKyrgyzstanLaosLatviaLebanonLesothoLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMexicoMoldovaMongoliaMontserratMoroccoMozambiqueNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPonapePortugalPuerto RicoQatarReunionRomaniaRotaRussiaRwandaSaipanSaudi ArabiaSenegalSerbia and MontenegroSeychellesSingaporeSlovakiaSloveniaSolomon IslandsSouth AfricaSouth KoreaSpainSri LankaSt. BarthelemySt. CroixSt. EustatiusSt. JohnSt. Kitts and NevisSt. LuciaSt. MaartenSt. ThomasSt. Vincent and the GrenadinesSurinameSwazilandSwedenSwitzerlandSyriaTadjikistanTaiwanTanzaniaThailandTinianTogoTongaTortolaTrinidad and TobagoTrukTunisiaTurkeyTurkmenistanTurks and CaicosTuvaluUgandaUkraineUnion IslandUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Virgin IslandsUzbekistanVanuatuVenezuelaVietnamVirgin GordaWallis and FutunaWestern SamoaYapYemenZambiaZimbabwe
How urgent is your need to get help for your participant?—Please choose an option—I must get help immediatelyI am looking for treatment within the next weekI am looking for treatment within the next monthI am just evaluating the options for treatment
What seems to be the greatest difficulty for your young adult?
Adults must be willing to commit to treatment.. Are you willing to commit to treatment? YesNo
Are there any legal or court issues pending? YesNo
Do you have access to the resources needed to pay for treatment? YesNo
If you chose to place your young adult in treatment, would you need to borrow funds? YesNo
