Youth Connect Registration Form

Youth Connect Registration Form

Welcome! We’re excited that you’re ready to get support and take charge of your mental health!
PLEASE READ: To connect with a therapist or counselor through the Youth Connect program, you must first complete this registration form with the right information. If you need help completing the form because you don't know all the info, ask an adult you trust for help or email us at youthconnect@thebraidfoundation.org.

Before you start the form, you need to pick your top 3 choices for therapists or counselors. Check out your options Click Here to Pick Your Top 3 Counselors.

If you are in a mental health crisis right now

Please use the numbers below. If you are in immediate danger or in a medical crisis, call 911.
If you are a young person in a mental health crisis and need help right now, please call 855-CRISIS-1 (855-274-7471). You will be connected to a trained crisis specialist in your area. You can also call the Memphis Crisis Center at 901-274-7447.
You can also text 988 or use the Lifeline Chat to talk to caring crisis counselors for emotional support. Lifeline's call, text, and chat services are available in Spanish. To speak with a Spanish-speaking crisis counselor, call 988 and then press 2. To text a Spanish-speaking crisis counselor, send the word AYUDA to 988.
LGBTQI+ people under 25 can get 24/7 support on 988. To call an LGBTQI-trained crisis counselor, dial 988 and press 3. To text, send the word PRIDE to 988. To chat, check the box for LGBTQI+ support in the Pre-Chat Survey.

Who is completing the registration form? *

If you are the parent or legal guardian completing this form for your child, please review the following:

1. This form is intended to be completed by the youth or the youth with a parent, trusted adult, or legal guardian.

2. If you are completing the form for the youth and the youth is not open to counseling or aware you are completing the form for them, please stop completing the form and check in with the youth before resuming the registration form.

3. If you need help or assistance in talking to your youth about going to counseling, please email, text, call, or visit our website for more resources.
Please check you understand the following:*

I understand that if I fill out this form without my youth knowing or being involved, the youth will be signed up for Youth Connect temporarily. Youth Connect will check in to see if the youth wants to participate. Please continue with the registration when the youth knows about it and is part of the process.

Your Name*

First NameLast Name
Age: *
Only ages 13-18 are eligible for services. Please email us if you need support for age 12 or younger.
Birth Date*

MonthDayYear
Preferred Pronoun*
Pronouns
Email Address*
example@example.com
Home Phone Number
Mobile Number*
How would you like us to contact you? *
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
What is your zip code? *
Only Shelby County residents are eligible.
What is your race/ethnicity*
What language do you speak? *
If you speak a language not listed, please list it below.

You are seeing this page because you stated you are under the age of 16.
By checking the box below, I understand I must get my parent's or guardian's permission to see a counselor/therapist, AND I give Youth Connect permission to contact my parent or guardian so I can go to counseling.*

I understand.I understand, but I need help talking to my parent(s) or guardian about counseling.

Your Reason For Counseling
Just a reminder, all the information you provide is private and confidential. We will not share it with anyone. What you tell us is only used to make sure we help you get connected to the counselor or therapist that is best for your needs.
We, including adults, all have different reasons or even multiple reasons why we need support. Here are some reasons young people may need therapy. Is one of these your reason to get counseling?

Feeling Stressed or Overwhelmed: When school, friends, or life feels like too much to handle.

Dealing with Anxiety or Worry: If you’re often feeling nervous or worried about things.

Feeling Sad or Depressed: When you’re feeling down or hopeless for a long time.

Relationship Problems: Having trouble with friends, family, or dating.

Self-Esteem Issues: Struggling with how you see yourself or feeling like you’re not good enough.

Dealing with Changes: Big changes like moving, changing schools, parents or someone important to you is going to jail or is in jail, or parents getting divorced or break-up.

Grief and Loss: Dealing with the death of a loved one or losing something important to you.

Managing Anger: Finding it hard to control your anger or getting angry a lot.

Bullying: Being bullied or having problems with other kids.

Exploring Identity: Figuring out who you are.

Dealing with Trauma: Going through or went through something really scary or upsetting, maybe you can't stop thinking about it.

Substance Use: Worrying about your own or someone else’s use of drugs or alcohol.

School Pressure: Struggling with schoolwork, tests, or thinking about the future.

Needing Someone to Talk To: Just need a safe space to talk about anything on your mind.
What is your main reason for going to counseling? *
In your own words, please describe why you want or need counseling. What do you need help with? *

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Do you want someone at Youth Connect to help you figure out what type of counseling or counselor is going to be best for you? *
In your own words, please tell us what you want in a counselor/therapist? What is most important when choosing the right counselor for you?

0/200
What type of counseling do you want?*

Individual Counseling (1 on 1)Both Individual & GroupGroup Counseling (with peers)I Don't Know

To make sure we get you to the therapist or counselor of your choice, please look at the therapist/counselor website before completing the following.
Click Here to Pick Your Top 3 Counselors
Please select your top choice (#1) for your therapist: *
Please select your second choice (#2) for your therapist: *
Please select your third choice (#3) for your therapist: *

Please select the type of group counseling you would like to join from the list below. If you want individual counseling only, please select N/A.

Family Information

.
UNDER the age of 16: If you are under the age of 16, you must have a parent's or guardian's permission to go to counseling.

16 or OLDER: If you are 16 or older, we just need your parent's or family's information in case of emergency, you don't have to get parental permission to get counseling in Tennessee.
Parent/Guardian's Name*

First NameLast Name
Contact Phone Number*
Parent/Guardian E-mail Address
example@example.com
My parent or guardian knows I am completing this form*

Let us know the best day(s) and time(s) for us to reach you. You can give examples like "Fridays after 5 pm," "any weekday evening," or "Saturday afternoon." This helps us make sure we connect at a time that works for you.*
We want to make sure you understand the following:
By completing this form, I give permission for Youth Connect to contact me about my counseling needs and connecting me to a counselor. If you select disagree, you will not be able to participate in the Youth Connect program.*

I give Youth Connect permission to contact me.I do not give permission and understand I can't participate in Youth Connect.
I understand that I won't be able to participate if Youth Connect can't reach me by the ways I provided (phone, text, email). Youth Connect will make several trys to reach you first.*

I understand I have to answer by phone, text, or email when Youth Connect reaches out to me.
By completing this form, I understand that Youth Connect and The Braid Foundation are helping me find counseling, but they will not be the ones who provide the therapy.*

I understand.I don't understand and need someone at Youth Connect to explain.
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Youth Connect Registration Form

If you are in a mental health crisis right now

You are seeing this page because you stated you are under the age of 16.

Your Reason For Counseling

To make sure we get you to the therapist or counselor of your choice, please look at the therapist/counselor website before completing the following.

Family Information

We want to make sure you understand the following: