YOUR CHILD IS NOT A NUMBER:
NAVIGATING THE CHILD ADOLESCENT NEEDS STRENGTHS TOOL WITH CONFIDENCE
Taking Place on 5/27/2026 from 12:00 – 1:30 PM MT
Some Quick Questions
This survey helps us understand what you already know and what you want to learn. There are
no right or wrong answers. Your responses help us make this training better for youth.
Will you be attending:
In Person
Virtually via Zoom
Do you need any accommodations to fully participate in this training?
Is there a specific question you hope gets answered?
Have you previously gone through the YES eligibility or assessment process?
Yes, my child is currently eligible for YES
Yes, but we were found ineligible
We are in the process now
No, but we are considering it
Before today, how familiar are you with how YES eligibility is determined?
Very familiar
Somewhat familiar
I've heard about it but don't understand it
Not familiar at all
How did you hear about this training?
Social Media
IPUL's website
A Flyer
Liberty Healthcare
Other
Information About You
Are you a:
Parent
Professional
First Name:
Last Name:
Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaskan Native
Other
Unknown
Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Phone Number:
Email Address:
Join Mailing List
If you would like to be on IPUL's mailing list check this box.
Mailing Address
Mailing City
Mailing State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
This address is my
Home
Work
Professional Information
Organization Name:
My Title:
Phone Number:
Only if different from above
Email Address:
Only if different from above
Information About Your Child
Please only enter information for an individual child, you will be able to add more children below.
Child's First Name:
Child's Last Name:
Child's Gender:
Female
Male
Child's Birthdate:
Child's Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaska Native
Other
Unknown
Child's Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Child's Diagnosis:
Do You Have Another Child to Enter?
Yes
No
Information About Your Child (2)
Please only enter information for an individual child, you will be able to add more children below.
Child 2's First Name:
Child 2's Last Name:
Child 2's Gender:
Female
Male
Child 2's Birthdate:
Child 2's Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaska Native
Other
Unknown
Child 2's Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Child 2's Diagnosis:
Do You Have Another Child to Enter?
Yes
No
Information About Your Child (3)
Please only enter information for an individual child, you will be able to add more children below.
Child 3's First Name:
Child 3's Last Name:
Child 3's Gender:
Female
Male
Child 3's Birthdate:
Child 3's Demographics:
Please select...
White or Caucasian
Black or African American
Asian
Pacific Islander
American Indian or Alaska Native
Other
Unknown
Child 3's Ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Other
Child 3's Diagnosis:
If you have more than three children that you need assistance with, our Parent Education Coordinator will take your information directly.
Training Information
Incredibly Important Back End Stuff
(Hidden from person filling form, but
needs to be set up when building the registration or everything will be for naught and you will spend several days trying to fix your data WITH WOE IN YOUR HEART AND A POX UPON YOUR HOUSE)
Funding Source
separate with semicolon and put in
Default Value
under
Options
EXAMPLE
:
MCHB F2FHIC; PTI
(THESE NEED TO MATCH SALESFORCE OR PAIN WILL RESULT)