Center for Humanistic Change - Program Request Online Form

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Please answer the following questions so CHC can assist you with your program needs.

Please select the ONE answer that closely matches your location.

School / Facility / Location Name

Location Address - Please include street, city, zip, county)

Name of the person completing this form

Phone Number

Email Address

Organization Contact Name and Title

Organization Contact Phone

Organization Contact Email

Does CHC already provide programming to you/your facility?

Yes

Who is your CHC Contact? (If known)

Do you need assistance in identifying or selecting programs to meet your needs?

Yes

Clear selection

Do you need assistance planning dates and times?

Yes

Clear selection

Choose Programs of interest (select all that apply)

Mock Teen Bedroom (For Adults 18+) Available for community events, health fairs, open houses; set up requires 12'x20' open space

Provide Information Table at community event, health fair, open house or other activity

Clear selection

Choose Programs of interest - Multi Session Evidence-Based Programs (select all that apply)

Botvin Life Skills (Student & Parent Training) - grades K-12, parents

Keep a Clear Mind - grades 4, 5, and 6

Project Towards No Drug Abuse - grades 9-12

Speaking to the Resilience of all Kids (SPARK)

Strong African American Families (SAAF) - families with ages 10-14

The Blues Program - grades 7-12

Too Good For Drugs/Violence - grades K-8

Second Step - grades K-8

STEP (Systematic Training for Effective Parenting) - parents of ages 6-12

STEP Teens (Systematic Training for Effective Parenting/Teens) - ages 13-18

Strengthening Families Program (SFP) - families with ages 10-14

Choose Programs of interest - Single Session Programs (* denotes Evidence-Based) (select all that apply)

Choices, Changes, Changes - grades 7 & 8

Current Drug Trends - grades 6-12, staff, adults

Cyber Gambling Awareness Program - grades 9-12, adults

HOPE ( Heroin & Opioid Prevention Education) - community

HOPE for HS Students - grades 9-12

HOPE for the Work Place - employers/employees

HOPE for Older Adults - adults

Mock Teen Bedroom - community ages 18+

Social Media - grades 4-12, parents

SOS - Signs of Suicide * - grades 6 - 12

The Vaping Epidemic - grades 5-12, adults, community

Small Groups - Life Skills (* denotes Evidence-Based) (select all that apply)

Anger Management (SAMHSA) - adults

Anger Management - grades K-12

Botvin Life Skills * - grades 3-12

I Can Problem Solve * - ages 4-12

Life Skills for Littles (Weekday Club) - grades K-8

FISH (Families in Separate Households) - grades 2-6

Healthy Choices Healthy Relationships - grades 10-12

Stress Management - grades K-12

PAYS - district specific programming/survey results - grades 6-12

Prevention Education for Adults - ages 18+

Describe the audience or class: (i.e. grade, age group, youth/parents, seniors, etc.) Include any language barriers to consider or other special needs.

Approximately how many people will be in attendance for the program?

Anticipated date(s) of program? (i.e. school year, semester, month, weeks, summer, or specific event date)

Anticipated length of program? (i.e. day, evening, times, flexible)

Is there any other information you would like CHC to know about your request?

If you have any questions or need any further information, please contact Stephanie Dorney, Manager of Prevention, Center for Humanistic Change via email to sdorney@thechc.org or call 610-443-1595.

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