I.N.S.P.I.R.E - Interest form

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This form does not guarantee you an immediate appointment, you will be contacted by the program coordinator, Miguel Duenas to schedule your first session.

Este formulario no le garantiza una cita inmediata, será contactado por el coordinador del programa, Miguel Dueñas para programar su primera sesión.

Email *

Record my email address with my response

First Name

Nombre

Last Name

Apellido

Which school do you attend?

¿A qué escuela asistes?

Jefferson

Oceana

Terra Nova

Westmoor

Clear selection

What grade are you in?

¿En qué grado estás?

Clear selection

What substance are you looking to get help with? (Check the appropriate boxes)

¿Con qué sustancia está buscando ayuda? (Marque las casillas correspondientes)

Alcohol

Marijuana (Marihuana)

Nicotine (Nicotina)

Pills (Pastillas)

Other (Otra)

What is your JUHSD email? (Please be sure to check this as I will send you a link to the REMIND channel for messages and updates)

¿Cuál es su correo electrónico JUHSD? (Asegúrese de verificar esto, ya que le enviaré un enlace al canal REMIND para mensajes y actualizaciones)

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