PHAT FUTURE MINDS

PHAT FUTURE MINDS
You have been selected to participate in a special mentoring/counseling program sponsored by Phat Future Minds. This exciting program will include out of home counseling as well as literacy and enrichment. Additional topics we plan to address are:

Housing Interpersonal Skills Health & Hygiene

Self-Respect, Self Esteem & Image Money Management Job Training

Our program will also offer you monthly groups, counseling session and education seminars away from the community. Please complete the bottom portion of this form and return it to a PRP Advocate of Phat Future Minds. One of our advocates will contact you within 24 hours to begin participating in the
Client Name*
Gender*
Date of Birth*

MonthDayYear
Date
Age*
Emergency Contact Name*
State ID/License*

Cancelof
2nd Verification*

Cancelof
Medicaid #*
Emergency Contact #*
Address*
City*
State*
Zip Code*
Primary Care Provider*
Social Security Number*
RC*
Client Signature*

Clear
**Medicaid information will allow Phat Future Minds to bill for services and field trips ***

403 Eastern Blvd Essex MD 21221

511A Eastern Blvd Essex MD 21221
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