Power To Choose Intake Form

Thank you for you interest in the Power to Choose! It is a unique Attitudinal Healing Innovation that is geared for youth. Founded on the philosophy of the Principles of Attitudinal Healing, the program aims to tap into the inner potential of youth in order to create leaders that make healthy and positive choices in their everyday life. Youth will be equipped array of tools to enhance their decision making a process, uplift their self-esteem, cultivate their leadership, and empower them to be agents of change.

Fill out and submit the form below, and someone will be in contact with you shortly.

Note: it is important to provide at least one form of contact information. 

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Power To Choose
Name *
Email *
Phone Number Optional: enter the best contact phone number
City and State Optional: enter your City and State of residence or service work
How did you hear about the Power To Choose program? Optional: please share your introduction to Power To Choose
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Are you affiliated with an Attitudinal Healing Center or Group? If so, please explain your involvement in the AH Center or Group. Optional: provide background information re: your involvement with Attitudinal Healing
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Please explain your interest in the Power to Choose program. Optional: provide some information as to why you are interested in the Power To Choose program
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