Appa Health Parent Sign Up Form

1
School Pay
Yes
No
2
FSUSD (DEPRECATED)
Yes
No
3
School District
4
What's your teen's name?* This field is required.
First Name
Last Name
5
Does your teen have an Individualized Education Plan (IEP)?* This field is required.
Yes
No
6
What are some areas where {whatsYour[1]} could use support? (Check all that apply)* This field is required.
Sadness, low mood, or loss of interest
Anxiety/worries
General stress management
Self-esteem/confidence
Social skills/building friendships
School engagement
Loss of a loved one
Behavior issues
Trauma
Loneliness
Concentration/focus
Motivation
Anger
Independence
Other
7
What's {whatsYour[1]}'s date of birth?* This field is required.
Date
Month
Day
Year
8
Does your teen have any visual, auditory, physical, or cognitive disabilities that could affect their ability to independently text and video chat with their mentor?* This field is required.
YESNO
9
Please provide additional context on your teen's disabilities and any accommodations that they may require.
10
Is there anything specific you'd like us to know about {whatsYour[1]}?For example: hobbies, interests, or current struggles.
11
How does your teen identify?* This field is required.
Male
Female
Non-binary
Prefer not to say
Other
12
Is your teen of Hispanic, Latino/a/x, or Spanish origin?* This field is required.
Yes
No
Prefer not to say
13
How would you describe your teen? (Check all that apply)* This field is required.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Prefer not to say
Other
14
Which of these options best describes your teen's sexual orientation?* This field is required.
Heterosexual or straight
Gay
Bisexual
Pansexual
Asexual
Not sure
Prefer not to say
15
How did you hear about Appa?* This field is required.
Event at school
From a teacher or counselor at school
Phone call from Appa
Email from Appa
From a fellow parent
From my teen
Google search
Social media
Other
16
Please select your teen's school (FSUSD)* This field is required.
Armijo High School
Fairfield High School
Rodriguez High School
Crystal Middle School
B. Gale Wilson Middle School
Grange Middle School
Green Valley Middle School
Dan O. Root II Health and Wellness Academy
David A. Weir Preparatory Academy
Oakbrook Academy of the Arts
Sheldon Academy of Innovative Learning
Virtual Academy
Other
17
Please select your teen's school name* This field is required.
Bentley School
Berkeley High School
Bishop O'Dowd High School
Eastside College Preparatory School
La Salle College Preparatory (Pasadena)
La Salle Catholic College Preparatory (Portland)
Lake Oswego High School
Saint Mary's College High School
Other
18
Please confirm your teen's school (Berkeley)
Berkeley High School
19
Please select your teen's school (Sonoma)
Analy High School
Casa Grande High School
Cloverdale High School
Credo High School
Elsie Allen High School
Geyserville New Tech Academy
Healdsburg High School
Maria Carrillo High School
Montgomery High School
Northwest Prep at Piner-Olivet
Petaluma High School
Piner High School
Rancho Cotate High School
Roseland University Prep
Santa Rosa High School
Sonoma Valley High School
Technology High School
Windsor High School
Other
20
Please select your teen's school (District 916)
916 Mahtomedi Academy
East View Academy
Metro Heights Academy
Project Return
Other
21
Confirm your full name (Parent/guardian name)* This field is required.
First Name
Last Name
22
Confirm your email * This field is required.
example@example.com
23
Confirm your phone number* This field is required.
Please enter a valid phone number.
24
What's {whatsYour[1]}'s address?* This field is required.We collect this information for emergency purposes only.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
25
Would you like to put down an additional emergency contact?* This field is required.
YESNO
26
Secondary Emergency Contact Name
First Name
Last Name
27
Secondary Emergency Contact Email
example@example.com
28
Secondary Emergency Contact Phone
Please enter a valid phone number.
29
Does your teen have a history of self-harm or suicide attempts within the past year?* This field is required.
YESNO
30
To ensure that Appa is a good fit for your teen, please provide some additional context about their self-harm or suicide attempt history.* This field is required.
31
Is your child at no/low risk for self harm?* This field is required.
YESNO
32
To ensure that Appa is a good fit for your teen, please provide some additional context about their history of self-harm.* This field is required.
33
I affirm that it is my responsibility to monitor my child for changes in behavior and to provide supervision and care for my child.* This field is required.
YESNO
34
To ensure that Appa is a good fit for your teen, please provide some additional context about your ability to monitor for and care for your child.* This field is required.
35
I affirm that I will contact my child’s physician or other licensed healthcare professional if I have any concerns about my child’s mental health.* This field is required.
YESNO
36
To ensure that Appa is a good fit for your teen, please provide some additional context about your ability to contact a healthcare professional.* This field is required.
37
What's {whatsYour[1]}'s phone number?* This field is required.We will reach out to your teen via text to help them choose a mentor. If your teen does not currently have their own phone, you may put your own number if you agree to provide access for your teen to contact their mentor.
Please enter a valid phone number.
38
What's {whatsYour[1]}'s email?
example@example.com
39
Text messaging opt-in* This field is required.
40
Terms and Conditions* This field is required.
41
Appa is available at no cost to Special Education students at Fairfield-Suisun Unified School District.

If your teen is not a Special Education student, please sign up here (Appa costs $200 per month, you can cancel at any time for a prorated refund).
42
Research consent (optional)We are partnered with the researchers at Johns Hopkins, University of Washington, and UCSF to help improve mental health support for teens. If you have any questions about our research projects, email us at info@appahealth.com
43
To finalize {whatsYour[1]}'s enrollment, we need your payment information. Click submit to go to the payments page.

We will not charge you until after your teen meets with their mentor. If the mentor match isn't right, we will completely refund your first session.

If you have any questions about payments or our refund policy, please schedule a consultation call with us here.
Should be Empty: