Your Name (required)

Your Email (required)

Telephone Number

Street Address:

City, State, Zip:

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Do you have a child currently in wilderness or residential treatment?
Yes No 

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If applicable, where is your child currently in treatment (name and location)?

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What kind(s) of information would you like to receive?
 Please call me; I would like to speak to someone about your program Please e-mail me more information about your program Please mail me an application packet

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Something else:

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