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First Name *

Last Name *

Home Phone *

Cell Phone *

Work Phone

Email Address *

Double check your email address for accuracy, we will be sending you a response.

Your Child's Name *

Gender *

Age *

If your child is under 12 years old we cannot assist you.

Date Of Birth *

Street Address *

City *

State *

Zip *

If other, describe here

Please click the issues that best describe your child:

What type of school/program are you interested in?

If you are searching for scared straight programs or boot camps we are not able to assist you. Contact your local sheriff's dept.

If other, describe here

If you are searching for Scared Straight programs or Boot Camps, we are not able to assist you. Please contact your local Sheriff's Department for possible resources.

What Locations in the United States are you most interested in? You can check more than one. *

East Coast

West Coast

Central States

All

What type of Medical Insurance does your child have? *

*If you have Medicaid or other state insurance and are searching for programs that accept these insurances, please contact your providers directly. Unfortunately, we don't have listings of programs that accept them. Most private residential therapy programs typically will only accept PPO insurance. There are usually financial options available through lenders with each school or program. Please review our page on Financial Options.

If other, describe here

Describe the situation that lead you to seek this service:

If you have any questions or comments please use the following space.You may also indicate the best place (home/work) and time to reach you.

How did you find us? (i.e. search engine (which one?), brochure, friend, co-worker, ad..)

Are you interested?

Yes, please email me the FREE chapter from your book "Wit's End: Advice and Resources for Saving Your Out-of-Control Teen"

The information that you provide on this form is kept confidential.

We help educate parents about the teen help industry and residential therapy programs that we have visited or have firsthand feedback on. We sometimes recommend adolescent services including schools, programs, treatment alternatives, therapists, and transport services; We do not own, control, manage, nor direct any individuals or companies that provide these services. We do not assume any liability or responsibility, implied or otherwise for said services. All liability or responsibility for any recommended services is assumed entirely by the service provider, as outlined in their individual enrollment agreements with the parent/sponsors.

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