TELL US ABOUT YOU

First Name *

Last Name

Email *

Phone *

State *

Zip Code *

County *

Other (specify):

Which best describes why you're here today? *

I want support or resources

I want to enroll a youth in a program

I want to volunteer

I want to partner with Legacies Empowered

I want to request a training or workshop

I want to submit a resource to the community directory

Something else

SUPPORT REQUEST

How would you like to receive support?

Help connecting to services

Resource Directory Only (Go to web page)

Are you seeking support for: *

Myself

My child

Someone I care for

A client / participant

Do you prefer: *

In-person therapy

Virtual therapy

No preference

Do you currently have transportation for in-person appointments? *

No, I want to do virtual therapy

Yes, I have my own transportation.

I have inconsistent transportation and may need support getting there.

What out of pocket pricing are you able to provide? *

up to $25 a session

up to $50 a session

My insurance will all cover expenses, I just need help in being connected to someone.

None of these options work for me.

What mental health challenges are you or the person being referred experiencing? Why are you interested in receiving support? Please describe. *

Is there anything else you'd like us to know in order to better support you? Please describe.

YOUTH PROGRAM ENROLLMENT

Youth First Name *

Youth Last Name *

How will youth get to the program? *

Will get a ride with family, friend, etc.

Will take the bus and NEEDS a bus pass

Will take the bus but does NOT need a bus pass

They do not have a ride and do not want to take the bus

Is youth involved in the juvenile justice system? *

Yes, currently

No, not anymore

No, never have been

Referral Source *

What is your relationship to the interested youth? *

I am the youth interested

Caregiver

Family Member or Friend

Professional Support System (Case Manager, Therapist, Court Official, etc.)

Caregiver Name *

Caregiver Phone Number *

Caregiver Email Address *

Is there anything else you'd like us to know in order to better support you? Please describe.

VOLUNTEER INTEREST

How often are you available to volunteer? *

Weekly

Bi‑weekly

Monthly

Occasionally

Are you willing to undergo a background check? *

Yes

No

Do you have transportation? *

Yes

No

What do you hope to gain from this volunteer experience? *

Any additional information or accommodations or support you need to volunteer successfully?

PARTNER WITH HUSTLE & HEAL

Business / Organization name *

What is your occupation, trade, or skill you are offering the youth? Please List Relevant Qualifications (Degree/Certifications) if applicable *

Is there a state or verified certification or licensure attached to your skillset? (i.e. STNA, cosmetology, CDL, etc.) *

Yes

No

If yes, what certification(s) or licensure(s) can you help a youth receive?

What days and times are you available to work with the youth? *

How many youth can you accommodate at one time? *

What days and times are you typically available to host youth? Example: “Weekdays between 9 AM – 3 PM” or “Saturdays only.” *

Do you have liability insurance to cover any bodily harm or damage to yourself or property? *

Yes

No

Are you willing to undergo a background check? *

Yes

No

Please provide any additional information or comments, you feel necessary or important to ensure a successful collaboration.

TRAINING REQUEST

Other:

What kind of training are you interested in? *

QPR (Question, Persuade, Refer) Suicide Prevention Training

Youth Mental Health First Aid - For adults supporting with youth

Teen Mental Health First Aid - For Teens supporting each other

General presentation around mental health & recovery

Invite us to have a Resource table

Other

Date of Event, if known

Please share anything Additional Details

RESOURCE DIRECTORY SUBMISSION

Thank you for your commitment to the community. Please tell us more about what the services you offer.

Organization or Practice Name *

Primary Contact Name *

Title / Role

Email Address *

Phone Number *

Website

Main Office Address *

City *

Zip Code *

County *

State *

Other (please specify)

Service Format *

In-person

Telehealth / Virtual

Both

Other (please list)

Brief Description / Notes for Directory Listing (2–3 sentences describing services, specialties, or approach — this may appear publicly.) *