If Heartlight is not right for your child, we can help you find a more appropriate program. Please go ahead and submit your information.

Financing available:

I'll promptly call or send any information you may need.

Melissa Nelson
Director of Admissions
and Referrals
903.668.2173 ext. 32
Fax 903.668.3453

I Need Help for My Teen!

First Name*
Last Name*
Address*
Town/City*
State*	e.g. AZ
Zip Code*	e.g. 75650
Phone	ext.
Fax
Email*
* Starred Items Are Required My Request (Choose one or both)
Call me.
Send me more information.
Alternate phone number and extension to reach me during daytime hours:
ext.
Best time to contact me (indicate AM or PM)
e.g. After 5PM MST
My Child's Gender
Male	Female
My Child's Age	(teenagers only)
Is this an emergency or urgent placement?
Yes	No
Note: Emergency pick-up and escort services are available.
Where did you FIRST hear about Heartlight?
e.g. Radio, web search, counselor, friend
Please describe your current situation and why you may need to enroll your teenager in a therapeutic program:


If the submit button does not work on your computer, press shift and drag your cursor from your name down to here to highlight the content, then press CTRL C. Then, open an email window and press CTRL V within the email to paste this information there. Send to admissions@heartlightministries.org.