GET HELP NOW

If you would like to know more about Certified Teen Help Organization and what we do, please see the About Us pages.

If you are uncertain about what services would help your child, order the Parent Teen Help Handbook.  The Parent Teen Help Handbook explains everything you need to know about various teen help provider types as well as services that are offeref in the industry. There are also therapeutic terms, tools, and information that could further benefit you and your child's relationship.

Seeking Help

Please be informed, the information you provide will be used by our system to select an appropriate organization to fit your child's needs.  Answer all the questions that accurately describes your child's needs and issues.

CONTACT INFORMATION
1. First Name
2. Last Name
3. Email Address
4. Primary Phone
5. Secondary Phone
6. Best time for a call	8 am to 11 am 11 am to 2 pm 2 pm to 5 pm 5 pm to 8 pm
7. What is your time zone?	PST (Pacific) MST (Mountain) CST (Central) EST (Eastern)
8. Which type of Provider would you like to be contacted by?	Program [?] School [?] Treatment Center [?] Specialty Program [?] Youth Transporter [?] Educational Consultant [?]
YOUR ADDRESS
9. Address
10. City
11. State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming --- Canadian Provinces --- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ------------ International Mexico
12. Zip
CHILD INFORMATION
13. First Name
14. Last Name
15. Gender	Male Female
16. Age
17. Birthdate	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
18. What types of issues is your child experiencing? NOTE: Please be sure to check all the issues that your child is having, so that our system can make the best fit for your child.	ADD/ADHD Aspberger Syndrome Anger management Anorexia Autism Behavior Problems Bipolar Bulimia Depression Drug and Alcohol Abuse Emotional Problems Gang Activity Learning Disorder Negative Peer Association ODD (Oppositional Defiant Disorder) Physical Abuse Pregnancy School Problems Sexual Abuse Suicidal Tendencies Other
19. Other issues and/or problems? Please explain.
PROGRAM INFORMATION
20. Preferred Program Location  (If applicable)	I would prefer a program close to home Anywhere, as long as my child receives the best treatment
21. Length of stay  (If applicable)	1-3 Months 6-9 Months 12 Months or more
22. Do you have a gender preference?  (If applicable)	Co-ed The same gender as my child
23. Urgency for Placement or Enrollment	Immediate (within 6 Days) Soon (7 to 30 Days) Later (After 30 Days)
Enter the characters you see here: (No Zero's)