The Salvation Army Children's Services HALO Project Application & Waitlist Form
Cost of the Program
Once your application is approved, an application fee of $250 will be due. The HALO Project has a fee schedule for trauma education classes and kids club for the ten week program. Insurance Payments are accepted for family therapy sessions with participating insurances. Families are responsible to pay insurance co-pays, if applicable. If the family’s insurance is not accepted private pay is accepted for therapy sessions. Adoptive families may qualify for Post Adoption Services through SWAN to cover program fees. Please speak with our HALO Project staff for more details about the fees associated with the program. Please complete all fields within the following form.
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Caregiver #1
Please enter all fields for Caregiver #1
Title
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Caregiver #2
Please fill out all fields below for Caregiver #2
Title
Name
First Name
Last Name
Email
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
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Date
-
Month
-
Day
Year
Date
Referred By:
Enter Name
Type of Insurance
Enter Insurance Type
Child's Age Range
*
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Child's Tee Shirt Size
Small
Medium
Large
X Large
2X Large
3X Large
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Social Worker's Name
First Name
Last Name
Social Worker's Number
-
Area Code
Phone Number
County
Enter County Name
DHS Worker's Name
First Name
Last Name
DHS Worker's Number
-
Area Code
Phone Number
Foster Agency (if applicable)
Enter Agency Name
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In families with more than one caregiver, will both caregivers be able to meet in the evening one night a week for ten weeks from 6:00 pm - 8:00 pm? Caregivers will participate in Trauma Education Classes while the target child participates in the Kids Club.
Yes
No
Caregivers are able to arrange childcare for child's siblings (if needed) while family is at HALO night.
Yes
No
Caregivers and child/teen agree to counseling sessions once a week during the day. The sessions will likely be held between the hours of 9:00 am and 5:00 pm. The day of the week varies. In families with multiple caregivers, both caregivers will be asked to participate.
Yes
No
If in foster care, the child/teen is unlikely to be reunified with bio parents before the completion of the project.
Yes
No
Child/Teen is a foster child or adopted child.
Yes
No
Child/Teen is experiencing behaviors such as acting out, stealing, lying, hoarding, hyperactivity, dissociation, inability to focus, learning issues, sleeping disturbances, etc.
Yes
No
Caregivers are aware and accept that their name will be on the HALO Waitlist which is monitored by a member of the HALO administrative staff.
Yes
No
Is the child/teen receiving counseling services at another agency? If the child is receiving services at another agency, it is likely that collaboration between HALO and the agency can occur.
Yes
No
Comments:
To inquire further about the program, please contact The Salvation Army Children's Services by calling (610) 821-7706.
If you have finished entering all information, then please click the submit button below. Thank you.
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