• Zen Zone After-School Day Treatment Interest Form

    Zen Zone Youth & Wellness provides structured after-school behavioral-health day treatment for youth ages 6–14. The program operates Monday through Thursday from 3:30–6:30 PM and includes therapeutic groups, emotional-regulation support, coping-skills development, social skills and family involvement.Zen Zone currently accepts youth enrolled in OhioRISE. Completing this form does not guarantee admission. Our team will review your information and contact you to discuss preliminary eligibility and next steps.This form is not monitored for emergencies. If your child is in immediate danger, experiencing active suicidal or homicidal thoughts, or requires urgent crisis support, call 911 or 988 or go to the nearest emergency room.

  • Parent/Guardian Information

  • Legally Authorized to Consent to Behavioral-Health Treatment?*
  • Any Custody Arrangements or Court Orders Affecting Consent?*
  • Format: (000) 000-0000.
  • Best Time to Contact You

  • Child Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What time is the child dismissed from school?*
  • Does the Child Have an IEP or 504 Plan?*

  • Program Eligibility and Schedule

  • Is the child currently enrolled in OhioRISE?*
  • Can the child regularly attend Monday through Thursday from 3:30 PM to 6:30 PM?*
  • Would the child need transportation from school if transportation is available from the school?*
  • Can an authorized adult pick the child up from Zen Zone by 6:30 PM each program day?*

  • Reason for Interest

  • What is the main reason you are interested in services?*
  • How are these concerns affecting your child's daily life?*

  • Safety Screening

    This form is not monitored continuously and should not be used during an emergency. If the youth is in immediate danger, call 911 or go to the nearest emergency department. For urgent mental or behavioral health support, call or text 988 or contact Ohio Mobile Response and Stabilization Services at 1-888-418-MRSS (6777).
  • Is the youth currently in immediate danger of harming themselves or another person?*
  • Within the past 30 days, has the youth talked about, attempted, or shown signs of suicide or self-harm?*
  • Has the youth ever attempted suicide or engaged in self-harm that required emergency or medical attention?*
  • Has the youth recently threatened, attempted, or caused serious physical harm to another person?*
  • Are there any other immediate safety concerns involving the youth?*

  • Current Services

  • What behavioral-health services is your child currently receiving?*
  • Does your child currently have a behavioral-health diagnosis?*
  • Is your child currently involved with any of the following?*

  • Group-Program Fit

  • What level of adult support does your child typically need in a group or community setting?*
  • Can your child participate in a small therapeutic group with staff support?*
  • Is your child generally able to follow basic safety directions with staff support?*

  • Parent/Guardian Acknowledgment

  • Please check each statement to confirm your understanding.*

  • Referral Source

  • How did you hear about Zen Zone Youth & Wellness?
  • Should be Empty: