Lamont Ingram Developmental Organization for At-Risk Children

 

 

 

"Reaching Our Youth For Tomorrow"

 

 

Out of respect to you and your child, Second Chance Developmental Treatment Center will keep all your information confidential. We only request this information in order to help provide the best guidance possible.

Fields marked with * are required.
Parent/Legal Guardian Name
Address
City
State
Zip Code
Telephone Number
Email Address
Would you like us to call you?


Is your child Male or Female?


Childs Name
Relationship to Child?
If Other?
Child's Age?
Previous Treatment or Placement?
Diagnosis
Major Issues:
Are you working with a Referring Professional?


If so, Who?

 

 

The Lamont Ingram Developmental Organization for At-Risk Children

©2008 I.R.S Approved 501 (C)3 Non-Profit Organization