Base Lemonaid CMS - We Connect Kids Form

1. Organization Name:

2. Web address (URL):

3. Email:

4. Phone:

5. Logo Upload (file format preferred: PNG):

6. Craft a brief and captivating description that will resonate with those who are seeking your services (150 words or less):

7. Check the ages your organization serves:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

8. Please check all services that apply to your organization:

Addictions

Crisis

Suicide

Groups for Parents

Family and Caregiver Support

Psychological assessments

Eating Disorders

Education

Parent Training

Day Treatment

In-home services

Fetal Alcohol Spectrum Disorder

Autism

Respite

Service Coordination

Prevention

Family Counselling

Peer Support

Individual Counselling

9. Please check off all words that apply to your services. These words could apply to the services you offer or mental health presentations of clients:

Anxiety

Worry

Depression

Sad

Withdrawn

Isolation

Aggression

Temper tantrums

Stress

Self-harm

Repetitive Behaviour

Social Anxiety

Trauma

Fears

Self-Esteem

Eating Disorder (anorexia, bulimia, binge eating)

Feeding

Mealtime

Addiction

Substance misuse

Alcohol

Pot

Drugs

Gambling

Screen time

Vaping

Smoking

Coping

ADHD

ADD

Anger

Bullying

LGBTQ+

Homosexuality

Transgender

Sexual Assault

Sexuality

Sexual Identity

10. Please list any applicable word not included in the above: