CLEAR - Anger Management Program

CLEAR - Anger Management Program

Please complete this form to register for the program.
All participants must:
- Have reliable internet access.
- Use a computer or device with a working camera and microphone.
- Keep their camera on for the entire session.
- Arrive on time - participants who are more than 5 minutes late will not be admitted.
- Attend all four sessions in order to receive a letter of completion.
- Notify the facilitator in advance if they are unable to attend a session.
- Be respectful and kind to all participants and the facilitator.
Failure to follow these requirements may result in removal from the program.
I am a youth registering myself.I am a parent/caregiver/caseworker registering a youth.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email address*
example@example.com
Parent/Guardian - Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
When is your next court date?*
Youth Information
Youth's Name*

First NameLast Name
Youth's Date of Birth*

MonthDayYear
Date
Youth's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Youth's Email
example@example.com
Referrer Information
What is your relationship to the youth?*
Other - Please specify*
Your Name*

First NameLast Name
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address*
example@example.com
YesNo
When is the next court date?
Parent/Guardian Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
YesNo
Will the parent/guardian be informed that the youth is being referred? Please explain.
Who should we send the Zoom link to for the sessions?*
Agreement and Consent
Attendance: I understand that participants must attend all sessions to receive a completion letter.
Confidentiality: I understand that information shared in the program is confidential, except where safety is at risk.
I consent to participate in the CLEAR Anger Management Program
I consent for the youth named above to participate in the CLEAR Anger Management Program.
I confirm that the youth named above is aware that they are being registered and have agreed to attend the CLEAR Anger Management Program.
By submitting this form, I acknowledge and confirm that all of the information provided is accurate.
Should be Empty:

CLEAR - Anger Management Program

Parent/Guardian - Emergency Contact

Youth Information

Referrer Information

Parent/Guardian Contact

Agreement and Consent