JHS-YR Mindset Intake Form

Please fill out the below information if you’d like to register for our next cycle of Mindset. Information from this form is submitted to our Program Coordinator. You will hear back from one of our staff members via your preferred method of communication, as soon as they can get to your matter. Thank you!

1. Full Name:

2. Preferred Name (a name you would like us to call you other than your legal name), if applicable:

3. Pronouns (what we would use to call you when replacing your preferred name. For example: she, they, he, xe, ze):

4. Telephone number:

5. Can we leave a confidential voicemail for you at this number?

6. E-mail address (if applicable):

7. Preferred method of communication:

8. Would you prefer us to communicate with you using a professional interpreter? (There is no cost to you for this.)

9. If yes, what language do you prefer?

9. Reason(s) for wanting to register for our anger management program: