Youth Intake Form

**Please note we are NOT a program. We only provide transport services to programs! (rehab centers, wilderness programs, and therapeutic boarding schools.)**

Youth Transport Intake Form

  • MM slash DD slash YYYY
  • Please enter a number from 10 to 17.
  • Please add a brief explanation if there have been any suicide and/or self mutilation attempts
  • Please list date, nature of incident(s) and any additional record information.
  • Name of treatment facility, youth is going to.