by pbcortex June 26, 2020 Form is successfully submitted. Thank you!Getting To Know YouDate*Last Name*First Name*Where have you been staying in the last week?DOB*Race/EthnicityGender*MaleFemaleOtherPhone*Email*Social MediaEnglish SpeakingYesNoPreferred LanguageDo you have any special needs or disabilities?YesNoIf yes, please explain:How did you hear about us?What do you need?CheckboxPeer MentoringMedical ClinicLegal Services/Justice InvolvedEmployment ReadinessHousing/PlacementHygiene ServicesAcademic Support Budget & Financial Planning Life Skills TrainingRecreation and ConnectivitySpiritual SupportReferral SourceReferralCCAVOSSNLSLABAPBOther ReferralReferral NameReferral TitleReferral PhoneReferral EmailPLEASE SELECT FROM BELOW Photo/Video/Audio Consent: Will be used for the purpose of publication, webpages, sharing recovery stories, and participant identification. The participant holds The Children’s Center of the Antelope Valley (W.E.D.O) harmless from and against any claim of injury or compensation resulting from the activities authorized of this consent.Consent OptionsConsent to photoConsent to video/audio recordingDecline to photo, video/audio recording (will be identifiable at events with a blue bracelet) SubmitPowered by ARForms (Unlicensed)