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A.R.C. Program Personal Referral Form

Name of Parent/Guardian(Required)
Name of Child(Required)
MM slash DD slash YYYY
Would you like us to text you to set up a time to call? If not, we will reach out by phone/email.(Required)
What goals/needs to you have for your family at this time? (check as many boxes as apply)(Required)
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)
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