Please be advised that your commitment with the Youth Aid Panel does require the completion of a paper with Aldersgate to be sent to your assigned counselor.

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age *

Gender

Race

Phone *

(###)

###

####

Email *

Parent/Guardian Phone *

Parent/Guardian Email *

School *

Were you referred by your school? *

If yes, what was the school incident that had you referred here?

Yes

Who is your in-school contact?

Please put "N/A" if you were not referred by your school

Phone number and email address of in-school contact: *

Did YAP send you here? *

Yes

Which YAP Panel are you working with? *

Please select the program you are signing up for: *

MBI (Caught vaping in school?)

TI (Caught underage drinking?)

INDEPTH (Did you have nicotine at school?)

Anger Management (Were you in an altercation?)

Retail Theft (Were you caught stealing?)

Peer Pressure

Social Media (Inappropriate texting/social media use)

Impulse Control

Coping with Violent Behaviors

Other (Description required in Message box below)

If sent by YAP, who is your panelist? *

This is the name of your weekly YAP contact (hint: you call them every week).

Phone Number/Email of Person Who Referred You: *

Please refer back to your YAP paperwork for this information.

In-Person or Virtual Sessions?

In-Person

Virtual

No Preference

Please choose the best days to meet with your counselor: *

Most sessions are scheduled after school hours. We do not offer weekend appointments.

Monday

Tuesday

Wednesday

Thursday

Friday

No Preference

If you have been given an exit date, please indicate date here:

YYYY

Message

Thank you for registering! You will receive an email within the next two business days confirming your enrollment and providing the next steps in the process.

Counseling, Outreach, & Prevention Education

Aldersgate is a Philadelphia area non-profit social services agency with skilled professionals addressing life issues for everyone. We receive partial funding through a contract with the Montgomery County Department of Health and Human Services - Office of Drug and Alcohol and Offices of Mental Health/Developmental Disabilities/Early Intervention. We are grateful for donations from the public, on which we are dependent for much of our programming.

Helpful Links
Counseling
Prevention Education
Student Assistance Program (SAP)
Alternative, Mandated Programs
Employment
Contact
Donate

49 Easton Road, Suite 203
Willow Grove, PA 19090
Phone: (215) 657-4545
Fax: (267) 518-0009

Let’s work together.

Counseling, Outreach, & Prevention Education

Counseling, Outreach, & Prevention Education Counseling, Outreach, & Prevention Education

Counseling, Outreach, & Prevention Education