Wild HeartsInterest Form Fill out the form below to let us know you are interested in Wild Hearts and we will be in touch soon. After you submit this application, you may request financial assistance by submitting the Wild Hearts Scholarship Application. YOUR INFORMATION Name First Name Last Name Email Address * Phone * (###) ### #### Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country IF YOU ARE THE PARENT OR GUARDIAN, PLEASE PROVIDE THE FOLLOWING INFORMATION: Please indicate the marital status of parents Never Married Divorced Currently Married Mother Remarried Father Remarried Other If you checked "Other" above, please describe: Support System of Participant (please check all that apply) Supportive Friends No or Few Friends Unsupportive Friends Substance-use-based friends Supportive Family Unsupportive Family Supportive Significant Other Unsupportive Significant Other Social Activities Enjoys Community Projects / Volunteering Attends Church Groups Attends Summer Camps Friends Other If you checked "Other" above, please describe: Participant's Hobbies Participant's Name Participant's Date of Birth MM DD YYYY Contact Info (phone/email) Is the participant currently attending counseling? (please provide name of therapist or clinic) Is the participant currently taking any medications? (please list all medications and frequency) Does the participant have any allergies? If so, what are they? Does the participant have any injuries we should be aware of? Please describe what factors or events have led you to seeking Wild Hearts at this specific time. What coping skills is the child or your family currently using? Please describe the goals that you might have for yourself, your family, and/or child for participating in the Wilderness4Life program? Has your child attended an Outdoor Behavioral Healthcare program (wilderness therapy, therapeutic boarding school, etc.) or inpatient/outpatient program? If so, which program? If your child has not attended an Outdoor Behavioral Healthcare program, and/or rehabilitation program, what is your current family situation and/or needs? Does a financial need exist? Yes No Thank you!
