Next Steps Form

How can we best serve you? Tell us the programs you're interested in and we will reach out to you in 2-3 business days.

Parent/Guardian Information

Parent/Guardian First name*

Parent/Guardian Last name*

Parent/Guardian Email*

Parent/Guardian Phone*

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Parent/Guardian Primary Spoken Language*

Student Information

Student First Name*

Student Last Name*

Student Primary Spoken Language*

Student Grade Level*

School where student attends*

Programs and Options

Which programs are you interested in learning more about? Choose all that apply*

The Torch: After-School Program

Pathway to College

Trailblazers Series

Volunteering

Move & Groove (and other enrichment activities)

Other

Do you currently have consistent access to basic hygiene products for your household?*

Yes

Sometimes

Would you be interested in support or resources to help manage anxiety or emotional well-being for yourself or your family?*

Yes

Maybe

Are you in need of any therapy/counseling for you or your family? Choose all that apply*

Individual Adult Therapy

Individual Child Therapy

Family Counseling

No services needed

Are you in need of any Community-Based Services? Choose all that apply*

Rent Assistance

Utilities Assistance

Employment

Food

Housing

No services needed

Other

Anything else you'd like to add?

10521 Blue Ridge Blvd.

Kansas City, MO 64134

Contact Us

Please fill out the form below and we will get back to you.

First name*

Last name*

Email*

Phone

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