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- Youth Intake Form

Companion Travel Services

Next Step offers transport services for seniors, people with autism, mentally challenged individuals, and more. Read more.

Youth Intake Form

**Please note we are NOT a program. We only provide transport services to programs! (rehab centers, wilderness programs, and therapeutic boarding schools.)**

Youth Transport Intake Form

"*" indicates required fields

Parent / Legal Guardian Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone*

Work Phone

Cell Phone*

Email Address*

Which Number Should We Use to Contact You*

Youth's Name*

Date of Birth*

MM slash DD slash YYYY

Age*

Please enter a number from 10 to 17.

Height*

Weight*

Distinguishing Marks? Tattoos, Piercings etc*

Substance Abuse*

Yes

No

Please Specify Substance (s)*

Alcohol

Cocaine

Hallucinogens

Marijuana

Inhalants

Cigarettes

Meth Amphetamine (Meth)

Prescription Drugs

Other

If You Checked "Other" Please Explain*

Violent Behavior*

Yes

No

If Yes, Please Explain*

Access to Weapons?*

Suicide / Self Mutilation*

Please add a brief explanation if there have been any suicide and/or self mutilation attempts

Arrest Record*

Please list date, nature of incident(s) and any additional record information.

Currently on Probation?*

Yes

No

Probation Officer Name / Number*

Medical, Psychiatric or Counseling History?*

Clinical Assessment? Any Disorder We Should Be Aware Of?*

Type(s) of Medication / Dosage Instructions*

Siblings?*

Adopted?*

Divorce Issues?*

Boyfriend / Girlfriend?*

Any Recent Losses?*

Future Goals?*

Name of Treatment / Recovery Facility*

Name of treatment facility, youth is going to.

Contact Person / Counselor*

Facility Address*

Will a Facility Representative Meet our Agents at the Airport for Adolescent Pickup?*

Yes

No

Educational Consultant Name*

Phone Number*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Agent Instructions / Additional Information*

How Did You Hear About Us?*

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