Parent Registration Form for Youth Wellness Program
Our Community Wellness & Creative Expression Program is Designed to Support Youth & Families through Behavioral Health Therapy, Resource Navigation, Mental Health Intervention, Emotional Regulation, Financial Literacy, Entrepreneurship and Life skills training. (OWN IT + PURITY OVER POVERTY) Primary Care Solutions Location: 2177 Mock Rd, Columbus, OH 43219. Transportation is provided for eligible families. We are currently accepting early registrations and intake for Counseling, Behavioral Health Assessments, and Program placement prior to the start date. Please complete this form to register your child and specify your support needs.
Parent / Guardian Information
Parent / Guardian Full Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Call
Text
Email
Relationship to Child
*
What services are you interested in?
*
Behavioral Health Services
Community Health Worker (CHW) Services
Case Management
Referral Programs
Parent Support
Mental Health Support
Life Skills Coaching
School support
1 on 1 behavioral support (Child)
1 on 1 behavioral support (Parent)
Parent literacy program
Family resources and navigation
Other
Appointment
Child Information
Child Full Name
*
First Name
Middle Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
School Currently Attending
*
Parent/Guardian Insurance Provider (if known)
Wellness Information
Are there any current goals you have for your child ?
Are there any emotional, behavioral, or social concerns you (Parent) need support in?
Are there any current areas your family needs support in ? ( Ex: Resources, Therapy support , Food, Housing, Programs etc. )
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
Acknowledgment Section
Acknowledgment of Form Purpose
*
I understand this is a registration and intake form for program placement and services
Acknowledgment of Transportation and Terms
*
I understand transportation and services are provided based on program availability and eligibility
Acknowledgment of Health assessment
*
I understand my child will take a health assessment
Consent to Contact
*
I consent to being contacted regarding enrollment and services
Acknowledgment of Service Terms
*
I Acknowledge, My child can instantly start to receive services
Submit Registration
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