Register Get Motivated Boot Camp

Parent's Full Name:
Teen's Name:
Teen's Age:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Work Phone(optional):
Email:
Tell us about your Teen:
Are you prepared to pay for the program and enroll your teen now? :
Will you be using Insurance, If Yes, What? :
Are you prepared to be involved in the program along with your teen? :
How did you hear about us? (Website) :

Teen Assessment(Check all that apply)

A simple question sends my teen into a rage.

It’s hard to get my teen up in the morning for school.

My teen frequently starts fights at home with us or his/her sibling(s).

My teen’s grades have dropped.
Previous grade avg. Current grade avg.

My teen refuses to go or stay in school.

My teen has been suspended time(s) from school.

My teen has been expelled from school.

My teen gets into fights.

My teen uses fowl language.

My teen smokes.

My teen uses alcohol/drugs.

My teen has threatened to run away from home.

My teen never laughs, appears to be unhappy or angry.

My teen refuses to do any chores around the house.

My teen may be involved in a gang.

My teen has been arrested. For What? When? How many times?

My teen is angry all the time.

My teen ignores curfew.

My teen has threatened to commit suicide.

My teen is or has been in professional counseling.

Get Motivated Boot Camp ♦ 3650 New Hope Road ♦ Aubrey, Texas 76227
Telephone: 940-365-1818 ♦ Fax: 940-365-1863