Are you a mom or dad who has a son that is out of control, taking drugs, gang banging or has spent time in juvenile detention?

Are you at a crossroads and realize it's now or never to Save Your Son?

If you would like to have your loved one considered for participation in an intervention program that is geared toward saving their African American or Latino son, please complete the form below.

The information you provide will be submitted directly to the television production team, as well as a team of therapists and counselors. By submitting this information you give the right to use the information below in connection with an intervention television series designed to help young men.

You acknowledge that you may not receive a response from this submission. IF YOU BELIEVE THAT THE SITUATION YOU DESCRIBE BELOW REQUIRES URGENT ATTENTION, PLEASE CONTACT AN APPROPRIATE CARE PROVIDER.

If you are chosen to participate you will be required to sign appropriate releases. Please remember that the person you are contacting us about cannot know about the possible intervention or offer of treatment in order to ensure the best chances for success.

PLEASE only submit YOUR information. DO NOT INCLUDE any information about the son that is in crisis. That includes,phone/cell numbers, e-mail or address

All Required Fields Are indicated with an asterisk.

Your Name (First & Last)*
Your name is required. Your Age*
Your age is required. Your Gender*
Please specify your gender. Your Ethnicity*
Please specify your ethnicity. Your Occupation*
Your occupation is required. Your City, State/Province (List Country If Outside USA)*
Your address is required. Your Email Address*
Your email is required. Does son in crisis have access to the email address listed?*
Please select. Your Primary Phone Number*
Your phone number is required. Your Primary Phone Number Type*
What kind of phone is this? Your Primary Phone's Owner*
Who owns this phone? Does son in crisis have use of the phone or voicemail at this number?*
Please select. Alternate Phone Number*
An alternate phone number is required. Alternate Phone Number Type*
What kind of phone is this. Alternate Phone Number Belongs To*
Who does this alternate number belong to? Does son in crisis have use of the phone or voicemail at this number?*
Please select. Son in Crisis Name (First & Last)*
Name of son in crisis is required. Son in Crisis Age*
Age of son in crisis is required. Son in Crisis Ethnicity*
Ethnicity of son in crisis is required. Son in Crisis Occupation*
Occupation of son in crisis is required. Son in Crisis City, State/Province (List Country If Outside USA)*
Address of son in crisis is required. What is your son's issue/compulsive behavior and how long has it been going on?*
Please explain. If it involves drugs/ or an addiction what is the frequency of use (or compulsive behavior) per day?*
Please explain. How many people would participate in an intervention?*
Intervention head count is required. Please describe your son's accomplishments and personality before the addiction/ problem and describe your son's personality and situation now.
What do you believe caused your son's downfall?
Why hasn't your son received help to overcome the problem/ crisis? Has your son received help before? If so, what type, when, and how long did the treatment last?
Please list your son's weekly activities and the people he spends the most time with.
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Link to a Video

STORY SUBMISSION FORM:
This is a legal document affecting your rights and responsibilities:

Please read it carefully before signing.

Please note: All names entered below must exactly match those in the above form.

I, agree to complete and submit this story submission form (the "Form") for the purpose of being considered to become a participant in the television show ("Save My Son"). I am making the representations, disclosures, and agreements described below in this Form so that Producer will continue to consider me to become a participant in the Series. If any disclosure or representation is false, misleading or incomplete, or if I breach any agreement made in connection with the Series, Producer may remove me from further consideration as a participant.

I agree that I have not made, nor will I ever make any false or misleading statements regarding the Program, my participation in the Program, or the person that I am submitting for appearance in the Program ("Subject"). I agree that I have not, nor will I engage in any deceptive or dishonest act with respect to the Program, including but not limited to informing the Subject about the intervention or offer of treatment, the intended outcome of the Program, or any confidential knowledge I have with respect to the Program.

Please type in your NAME here which signifies that you are agreeing to the above terms of the Story Submission Form*
Tell us who is the subject of this story.

Please check this box which signifies that you are agreeing to the above terms of the Story Submission Form.*

Please make a selection. Confirmation Phone*
A confirmation phone number is required. Date*
Today's date is required. Person that is the subject of the story: * Tell us who is the subject of this story.

If you are experiencing any technical difficulty, please copy and paste the above questions and answers into an email with your contact information and send your message to Info@powerhouseproductions.tv.

501 Central Ave, Orange, NJ 07017 | e: Info@powerhouseproductions.tv
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