PATH 2 Purpose Permission to Contact

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sQMtEacEILbhSsTTpbRC2wK9LQCZi3rLeYuqgFFs5k2MzncQMqGamumwfCCuDx7WLmVzw3sQtbEwALEMZVvxL4R8veCYPkGTo

ARE YOU A TEEN 13 - 19 YRS OLD?

STRESSED? OVERWHELMED? FEELING DOWN OR BLAH?

Path 2 Purpose (P2P) is a free, voluntary study for teens who want to improve their mood & learn coping skills to manage difficult situations.

You or your parent can sign up for a Path 2 Purpose staff member to contact you.

Your answers will be kept confidential.

Date contact form started (TODAY-SERVER)

M-D-Y

First name

* must provide value

Last name

Date of birth

M-D-Y

Phone number

City

State

Zip code

First name

Last name

Phone number

Is there a doctor, practice, or clinic that ______ usually goes to for medical care?

Yes

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Is the place ______ usually goes for medical care part of one of the health systems on this list?

If not, or if you are not sure, please choose "Other" or "Not sure" and give the name of the clinic or practice below.

Advocate

UI Health, UIC, or Mile Square Health Center

Norton Health Care/University of Louisville

KSB

Other health system

Not sure

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Doctor, practice, or clinic where ______ usually goes for medical care.

Which Advocate clinic does ______ go to?

Advocate Des Plaines Pediatrics

Advocate Evergreen Park

Advocate Glenbrook Pediatrics

Advocate Yacktman Pediatrics

Other Advocate clinic

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Which other Advocate clinic?

Which UI Health, UIC, or Mile Square clinic does ______ go to?

UIC Medical Center

Maxwell Family Medicine

Mile Square Health Center--Back of the Yards

Mile Square Health Center--Cicero

Mile Square Health Center--Englewood

Mile Square Health Center--Main Location (Medical District)

Mile Square Health Center--South Shore

Other UI Health, UIC, or Mile Square clinic

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Which other UI Health, UIC, or Mile Square clinic?

Which Norton Health Care/University of Louisville clinic does ______ go to?

U of Louisville Cardinal Success Academy at Shawnee

U of Louisville Pediatrics Downtown

U of Louisville Pediatrics Eastern Parkway

U of Louisville Pediatrics South/Stonestreet

Fern Creek Pediatric Clinic

Okolona Pediatric Clinic

Other Norton Health Care/U of Louisville clinic

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Which other Norton Health Care/University of Louisville clinic?

Which KSB clinic does ______ go to?

KSB Amboy Clinic

KSB Ashton

KSB Edwards Clinic

KSB Family Health Center

KSB Mt Morris

KSB Oregon

KSB Polo Clinic

KSB Town Square Center

Other KSB clinic

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Which other KSB clinic?

I prefer to be contacted by (please check all that apply)

Phone

Text

I am a...

Teen

Parent/caregiver

Provider/teacher/trusted adult

Other (please specify below)

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Other category, please specify

Name of provider/teacher/trusted adult (optional)

Institution of provider/teacher/trusted adult (optional)

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