Teens Path to Success Foundation - A Child in Crisis is a Family in Need
REQUEST FOR ASSISTANCE
Name
Address
City, State, Zip
Phone
Email address
Child's name
Child's Date of Birth
List diagnosis/problem
Please check all that apply:
Currently under Physician's Care
Currently in a Treatment Program
Referred to/seeking Residential Treatment Program
Seeking an Alternative School
Currently receiving medication
Currently under Family Counseling
Seeking Medication Management
Seeking Family Counseling
Currently under Medical Nutritional Guidance
Seeking Medical Nutritional Planning
Seeking Educational Guidance
Outstanding balance due for care
Seeking financial assistance for continued care
Seeking partial financial assistance for treatment
Seeking full scholarship for Residential Treatment
ACCEPTANCE WILL BE BASED ON NEED, FUNDS AVAILABILITY AND CERTIFICATION OF NEED BY A LICENSED FACILITY, SCHOOL AND OR PHYSICIAN/THERAPIST.  RELEASE FORMS WILL BE REQUIRED IN ORDER TO UPHOLD ALL HIPAA REGULATIONS.
 
 
500 Governors Drive, Huntsville, AL 35801                256.518.9998        www.teenspathtosuccess.org
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