Sessions Participant Application (CLTS)
Please ONLY use this form if your child is part of CLTS. Use the other provided form if they are not. 

Crossfire Ranch offers one-on-one and group sessions to youth who are struggling with emotional/social and mental well being due to past trauma, current crisis or other circumstances that deeply challenge their sense of worth, belonging and purpose. 

Please share the following information regarding the child or teen who is considering participation.
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Participant's First Name *
Participant's Last Name *
Participant's Date of Birth *
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Gender *
Ethnicity *
Family Information.                                                  
Please share the following information regarding the child or teen's family.
Please list names, ages, and relationship to participant of household members.  *
Contact Information
Please provide the following contact information for the best adult point of contact for the child or teen.                
Caregiver's First Name *
Caregiver's Last Name *
Is the above adult the child/teen's legal guardian? *
If "no", please describe your relationship with the child/teen. *
Best Phone Number (no work numbers please unless that is the only option) *
Best Email (we use emails, please offer the one you regularly check)  *
Street Address *
City *
State *
County *
Zip/Postal Code *
Emergency Contact First Name (please choose someone who would be locally accessible in case of emergency at the ranch) *
Emergency Contact Last Name *
Emergency Contact Phone *
Secondary (not primary care giver) Emergency contact: First Name *
Secondary Emergency Contact Last Name *
Secondary Emergency Contact Phone *
Participant Description
This section will help us have a better understanding of how we may best serve the child or teen              
Child/Teen has a history of *
Required
Child/Teen currently struggles with: *
Required
Do you feel your child is currently experiencing a crisis/ (for example: isolation, depression, anxiety, missing school or struggles in performing daily functions, suicide ideation or attempts) *
How long has the child/teen been struggling with these issues? *
Child/Teen Potential Areas of Development
Crossfire Ranch programs are designed to help children grow and develop emotionally, spiritually, physically, relationally.
Please identify the top five (5) outcomes you hope to see in the participant *
Required
Child/Teen Strengths and Character traits (i.e. child is very compassionate) *
Do you identify with a place of worship? If so, where? *
Name of Referring Social Worker  *
Social Worker's Email *
Child/Teen currently under the care of Therapist/Psychologist (name): *
Please list any current diagnoses *
Does the Child/Teen have any allergies? (environmental, food, medication) Please list all that apply) *
Please describe any physical/mental limitations *
Please describe any past or present assault/aggressive behavior *
Is there any history of animal abuse *
Please share anything you feel would be helpful in understanding the child/teen's situation. *
What other services and/or activities is your child participating in?  *
Program Information and Availability
Participants begin with weekly 1:1 sessions. Different opportunities are added such as small groups, increased leadership and so forth. Our goal is to structure their ranch time according to the participants challenges and goals as much as our capacity allows. 
Please indicate your availability for participation - please list as many as would work that would assure the participant would have transportation. (Please note that we currently hold sessions M-Th. We will expand this when we have capacity to do so.) *
Required
Programs applying for, please check all that apply *
Required
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