A.R.C. Program Personal Referral Form Name of Parent/Guardian(Required) First Last Name of Child(Required) First Last Child's Date of Birth MM slash DD slash YYYY Best Phone Number(Required)Would you like us to text you to set up a time to call? If not, we will reach out by phone/email.(Required) Yes No Email(Required) Thornwell Email Updates Consent(Required) I would like to receive updates from Thornwell.By checking this box, you are agreeing to receive email updates from Thornwell's A.R.C. Residential Program. Your information will remain private and used only for informational purposes on your behalf.Zip code where you and your child reside:(Required) What goals/needs to you have for your family at this time? (check as many boxes as apply)(Required) Caregiver-child bond (attachment concerns) Help with behavioral issues My child's mental health Help with parenting skills Help with school related concerns Child struggles with relationships with siblings or peers Other If you answered "Other," please explain.Please note this is not a 24/7 monitored intake system. If you are in danger or feel you may be a danger to someone else, please contact the appropriate resource, such as 911. How did you hear about the A.R.C. Residential program?(Required) Doctor School A family who participated in the program Another professional involved with my family (Mental Health Counselor, Occupational Therapist, Speech Therapist, etc) Social Media Online search for help Post-legal adoptions Other Name of Referral Source(Required) If you answered "Other," please explain.