About

Family Interest Form

Please complete this form for an initial conversation. Do not include emergency information here. If this is an emergency, call 911.

Parent / Guardian Name * Relationship to Child * Email * Phone * City / State

Child Name * Age * Date of Birth Gender Current School / Program

Current Living Situation Primary Concerns / Challenges Has the child had behavioral concerns?

Yes No

Has the child had counseling / therapy?

Yes No

Any history of hospitalization for mental health concerns?

Yes No

Any current safety concerns?

Yes No

If yes to any safety concerns, briefly explain

Why are you reaching out to Seamark Ranch? What are your hopes / goals for your child? Best time to contact you

I understand this is an initial inquiry form and not an emergency service. *