check

New Student Information Sheet

Please complete this form by responding to all questions.

(Note: Response are needed in order to move to the next question)

Click the button below to start.

Start

Question 1 of 16

Name: 
(FIRST NAME │MIDDLE │ LAST NAME)

Question 2 of 16

Email:

Question 3 of 16

Phone:

Question 4 of 16

Date of Birth:

Question 5 of 16

Age Group:

A

17 or below

B

18-24

C

25-34

D

35-44

E

45-54

F

55-64

G

65 or older

Question 6 of 16

Are you Homeless?

A

Yes

B

No

C

Prefer not to say

Question 7 of 16

Veteran Status

A

Yes

B

No

C

Unknown

D

Decline to State

Question 8 of 16

Who referred you?
(CBR │ School │ Other)

Question 9 of 16

Address 

(Street)

Question 10 of 16

Address 

(City)

Question 11 of 16

Address

(State)

Question 12 of 16

Address

(Zip)

Question 13 of 16

Race

A

Native American or Alaska Native

B

Asian

C

Black or African American

D

Hispanic or Latinx

E

White or Caucasian

F

Unknown

G

Other

Question 14 of 16

Ethnicity

A

Hispanic

B

Non-Hispanic

C

Indigenous

D

Prefer Not To Say

Question 15 of 16

Gender

A

Female

B

Male

C

Female (Trans)

D

Male (Trans)

E

Prefer not to say

F

Other

Question 16 of 16

I understand that my records are protected under the Federal Regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and HIPAA and cannot be disclosed without my written consent unless otherwise provided for in the regulation. 

 

If I sign up for TPA services without legal mandates to do so, this release will expire thirty days after I complete the TPA funded program and/or services, successfully or unsuccessfully. I also understand that I make revoke this consent at any time except to the extent that action has been taken in reliance on it.

 

I also understand that recipients of any information disclosed in accordance with Part 2 of the Title 42 CFR or HIPAA may re-disclose it only in connection with their official duties.

 

(STUDENT SIGNATURE │ DATE │ PARENT SIGNATURE │ DATE)

Confirm and Submit