Organization Information

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* 1. What is your organization's name?

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* 2. Who is completing this form? (full name)

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* 3. What is your email address?

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* 4. What is your website address?

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* 5. What counties/boroughs do you provide youth peer services within?

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* 6. What age range do you provide youth peer services for?

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* 7. What settings do you provide youth peer services within? (Check as many as apply)

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* 8. What is your current funding source(s) for youth peer services?

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* 9. If you currently bill for YPA services, what is your rate?

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