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Enroll in Youth Peer Group

This form is intended for those who wish to enroll in, or receive more information about, our youth APG program. This program is for individuals ages 12-17 and ages 18-25 with, or at risk for, problematic substance use habits. Please provide us with your information so that our program manager can reach out to you within 48 business hours. We are currently enrolling youth in our weekly groups.

Who is filling out this form?*
- Youth seeking services
- Adult seeking services for a youth
Youth First Name*
First
Adult First Name*
Last
Youth Age Group*
- Ages 12-17
- Ages 18-25
Best Phone Number To Reach You*
Okay to leave voicemail?*
- Yes, you can leave a voicemail
- No, don't leave a voicemail
If you select "No" we will try to reach you a total of three times without leaving any voicemails.
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- Sign up for email donation receipts
- Sign up for fundraising updates
- Sign up for our newsletter
- Other comments/questions
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- I understand that ARCNH may occasionally contact me with updates on programs and events and I may unsubscribe at any time.

Contributor Contact

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Organization Name*
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Phone
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Please select the option that matches most closely to why you are contacting us today.
- Sign up for email donation receipts
- Sign up for fundraising updates
- Sign up for our newsletter
- Other comments/questions
Your Message
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- I understand that ARCNH may occasionally contact me with updates on programs and events and I may unsubscribe at any time.

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