Youth Recovery Mode After School Programming 2026-2027
About
Youth Recovery Mode (YRM) serves youth ages 12–21. Our after-school program is dedicated to empowering and supporting teens in our community. Enrollment is first come, first served. Once an application is submitted, YRM staff will confirm the teen’s placement in the program.The program is free of cost. Orientation will take place on January 29th from 3:00 PM to 5:00 PM. Programming will be held on Tuesdays and Thursdays, beginning February 3rd, Location: Eddie’s House 5901 Market Street, Suite 106Philadelphia, PA 19139. Snacks will be provided. For additional questions or information, please contact the Youth Recovery Mode Team: Iris Chase Youth Program Specialist Iris.Chase@odaatphilly.org and Weldon Gibson Youth Program Clinical Coordinator weldon.gibson@odaatphilly.org 267-881-2747 Instagram: @yfm.odaat
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Youth Info
Youth First and last name
First Name
Last Name
Youth's Phone number
School
Grade
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Trans male
Trans female
Gender nonconforming
Other
Pronouns used
She/her/hers
He/Him/His
They/them/theirs
Other
Ethnicity
Black or African American
White
Asain
Hispanic, Latino, or Spanish
American Indian
Middle Eastern
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Social Media
Our team has often found that youth prefer to communicate through social media. If you feel comfortable please add your Instagram account info so we can stay in touch via DMs as well as phone contact. Follow our account @yfm.odaat
Youth's Instagram
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Parent/ Guardian Information
Parent Name
First Name
Last Name
Parent Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to youth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does youth have permission to walk home?
Yes
No
My child/children will be picked up by parent/guardian
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Emergency Contact
Contact Name
First Name
Last Name
Relationship to youth
Contact Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
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Medical Information
Does the youth have any medical restrictions? If non-put NA
List and allergies youth may have if non-put NA
List any medication youth is taking if none-put NA
In the event of an emergency does ODAAT staff have permission to seek medical treatment for youth?
yes
no
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Behavioral health Information
Does the youth have a behavioral health diagnosis?
ADD/ADHD
Depression
Anxiety
PTSD
Issues with regulating emotions (anger, sadness, etc)
Is youth currently in treatment for mental health diagnosis?
Yes
No
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Additional Info
Is there anything else you would like YRM staff to know about your youth? Please explain below
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ODAAT Consent Form:
Before your voluntary admission into ODAAT, Youth Recovery Mode (YRM), you have the right to an explanation of the type of service you will receive:- I understand that my child will utilize room space at Eddies House HQ office at 5901 Market St Suite 106, Philadelphia, PA 19139.- I understand that my child and family may be invited to ODAAT special events.- I understand that signing this documents relieves all liability from ODAAT. - I understand that the services being offered to me/my family are voluntary.- I understand that it is my right to revoke this consent at any time.
I have read ODAAT consent in full and understand:
Yes
No
I agree with the ODAAT consent and authorize ODAAT to carry out duties listed above:
Yes
No
Signature
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Confidentiality
I understand that a record of my child's progress in this program/camp will be maintained by the ODAAT YRM staff. All information will be protected according to legal standards of privacy and confidentiality. No part of my child's record may be released to any agency or person without my authorization, except mandated by law as required by regulatory agencies. I understand that information about my child's participation in this program/camp will be used anonymously to create reports for funding and program outcome measurements. ODAAT YRM services for my child/ family will be effective upon providing virtual signature below and will be continued for a period of 3- 6 months, unless further services are needed.
I have read YRM Confidentiality in full and understand:
Yes
No
Signature
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YRM Consent Form
Youth Recovery Mode is an early intervention program sponsored by Philadelphia’s Department of Behavioral Health. The program will support for youth ages 12-21 years and their guardians, Youth who are truant, have frequent suspensions and are at risk of drug/alcohol use are especially welcome. The goal of the program is to empower children to make better decisions leading to a better quality of life. This program encourages 100% parent participation. Please review the statements below with your youth.
I will respect myself, and those around me. I will be attentive to instruction and participate in group and individual sessions.
Yes
All information received via this program will not be shared unless I give my consent and/or I am a danger to myself and/or others.
Yes
I will work to attend weekly sessions as scheduled by Youth Recovery Mode. All incentives (I.E trips, giveaways and sponsored getaways) will all be depended upon me appearing frequently and meeting 85% of the required group sessions.
Yes
As a member of Youth Recovery Mode, I will re frame from drug use and other illegal behavior that would postpone my growth and progression.
Yes
Signature
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Photography/Video Release
-I consent to the taking and use of still photography and/or motion pictures of me or my minor child for use by magazines, televisions, newspapers, etc. and to use the non-commercial use of such photographs for motion pictures. -I consent to the interviews by magazines, newspapers, television, etc. and to use the use by the media of any and all information I discuss and disclose in such an interview. -I understand that One Day At A Time (ODAAT) Youth Recovery Mode Program has no control over is not responsible for the content of any article, broadcast or other publication arising out of, or related to, the information provided by me in such an interview. -I hereby and forever waive payment or royalties for the exhibition or showing of photographs or motion pictures and/or the use of information provided by me.
I have read Photo/video release in full and understand:
yes
no
Signature
Submit
Submit
Should be Empty: