Club 17 Referral & Interest Form

Club 17 Referral & Interest Form

(Recovery-Focused Youth Program)
Club 17 is a Youth Recovery Organization providing structured Recovery Support Services (RSS) for youth navigating substance use and related challenges.

This short form helps us determine whether Club 17 may be a good fit. A screening conversation is required before enrollment.
- Youth/Attendee Name*
  
  First NameLast Name
- Preferred Name*
- Pronouns
- Date of Birth*
  
  MonthDayYear
  Date
- Age*
- Youth Phone Number (If Applicable)
  Please enter a valid phone number.
- Youth Email (If Applicable)
  example@example.com
- Parent/Caregiver name
  
  First NameLast Name
- Parent/Caregiver Phone Number
  Please enter a valid phone number.
- Parent/Caregiver Email
  example@example.com
- Referral type
  
  Youth (Self-Referral)Parent/CaregiverSchool StaffProviderAustin17House StaffOther
- Referring Person/Agency
- Best Contact Person
  
  First NameLast Name
- Contact Phone Number
  Please enter a valid phone number.
- Contact Email
  example@example.com
- What is leading you to explore Club 17? (Select all that apply)
  
  Curious about my substance use or habitsWant support or guidanceSomeone suggested itLooking for a recovery-focused spaceNot sure yetOther
- Is the youth/attendee open to participating in structured Recovery Support Services, which may include weekly Discovery Sessions (group support)?
  
  YesMaybeNot Sure
- Is the youth/attendee willing to attend consistently if accepted?
  
  YesMaybeNot Sure
- Is the youth/attendee currently receiving any support services?
  
  (Select all that apply)
- Individual therapyRecovery support services / recovery coachingSchool-based supportCourt/probation involvementNone at this timePrefer not to say
- Youth/Attendee may be navigating:
  
  (Select all that apply)
- AlchoholCannabisNicotineOther substancesCompulsive or addictive behaviorsExploring questions about usePrefer not to specify
- Are there any immediate safety concerns we should be aware of before scheduling a screening conversation?
  
  YesNo
- If yes, please explain
- Preferred contact method:
  
  PhoneEmail
- Best time to reach you:
- I understand this form does not guarantee enrollment. A screening call is required before participation in Club 17*
  
  Yes
- Youth/Attendee Signature
  
  Powered by Jotform SignClear
- Date
  
  MonthDayYear
  Date
Should be Empty: