PCM is a program designed to identify high risk youth and adults ---

To determine high risk behavior and develop behavior modification skills through

One on one counseling

 

YO ACAP Questionnaire

Have you ever had unprotected sex?                                                    YES NO

Have you ever had sex while high?                                                       YES NO

Have you ever had a sexually transmitted disease?                           YES NO

Have you ever thought of beingan exotic dancer?                              YES NO

Have you ever paid for sex?                                                                  YES NO

Have you ever cheated on your partner?                                              YES NO

Have you ever used a condom in the beginning of the relationship,
then as the relationship went on you stopped using the condom?    YES NO

If you answered yes to ANY of these questions then you are eligible to take part in YO ACAP's program
"Hard Knocks Life".On the space provided for you on the back please fill in the information.

THIS INFORMATION IS KEPT CONFIDENTIAL

Name                   

E-mail                   

Nickname           

Phone #               

Best time to call

Address               

City                            State         Zip

Question/Comments:

Please contact me as soon as possible.

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Copyright © 1998-99 YO ACAP]. All rights reserved.
Revised: January 07, 1999.