C.A.E. Student & Family Support Services Form

Student & Family Support Services

Please complete form in its entirety to the best of your ability. You will be contacted by a Team Ambassador within 24 hours of submission.
How Did you Hear About Us?*
CAE Crisis Response Team Partners
Name*

First NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Best Time to Call

Hour Minutes

AM/PM Option
Email
example@example.com
Have things been so bad lately that you have thoughts that you would rather not be here?*
Additional Services Needed (Check all that apply):

Legal AssistanceMental Health/GriefCash AssistanceTransportationClothingFoodChildcareSpiritual SupportDomestic ViolenceAdult EducationRecovery SupportOther
Please briefly describe the assistance you need with any additional comments.
ATTESTATION*

I certify that all the information I have given is true and accurate to the best of my knowledge and belief. I agree to provide financial and other verification that may be needed to receive services. I also acknowledge to having the right to refuse any services offered by Community Arts Experience, Inc. or any of their designated health care and/or service providers.
E-Signature*

Clear
Should be Empty: