Form for group homes that use Relief for Hurting Parents
and/or Teens Fight Adult Corruption in disciplining kids,
staff training, and/or to improve the home environments
to which children will be returning...

Please complete as much of the following form as possible. If you do not want specific information disclosed, please indicate which items in the additional comment area.

Name of Organization or Business: Statement of Purpose: Mailing Address: City: State or Province:   Zip: Physical Address (if different): City: State or Province:   Zip: Country: Near what landmark: E-mail: Web Page: Director's Name:   E-mail: Counselor's Name (1):   E-mail: Counselor's Name (2):   E-mail: Counselor's Name (3):   E-mail: (Please use additional information area to list any other important contacts.) Business Hours: Time Zone: Business Days: Contact Person: Contact Phone Number:   Best time to call: I/We use Relief for Hurting Parents and/or Teens Fight Adult Corruption when working with clients. Does your group home, boy's home, girl's home, youth ranch, live-on-campus treatment program, boot camp, or military academy have openings? Yes    No If so, what is the approximate per-month cost of placing a child in your facility? What are the basic requirements for placement? Does your program qualify to serve readers of Relief for Hurting Parents in harmony with the basics of the guidelines for choosing a treatment facility in chapter 28 of Relief? Yes    No Are there counselors at your facility or who serve your facility by contract who counsel in basic harmony with Relief and who provide counseling or therapy to children and families who do not have a placement in your facility? Yes    No Additional information or comments:

By submitting the above information to buddyscott.com for posting to the Directory of Contacts, I agree that I have read and support the basic concepts and principles found in Relief for Hurting Parents.

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