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Confidential Assessment
Please complete the following questionnaire to determine if your child may need placement services. All information submitted is confidential. The results will be displayed upon pressing the submit button.
Has your child had recurring problems due to...
Any traumatic events or changes in his /her life? (i.e. abuse, divorce, death,etc.)
Yes
No
Inability to manage anger
Yes
No
Within the last six months, has your child:
Had any changes in behavior and / or mood? (i.e. sad, angry, withdrawn, etc.)
Yes
No
Exhibited depressive symptoms? (i.e. weight loss, weight gain, excessive sleep, etc.)
Yes
No
Had problems getting along with others?
Yes
No
Do you suspect that your child has used drugs or alcohol?
Yes
No
Has your child disregarded family rules and parental guidance?
Yes
No
Has you child been able to escape consequences due to the ability to manipulate people and situations?
Yes
No
Had problems in school? (i.e. poor grades, challenging authority, etc.)
Yes
No
Intentionally frightened others?
Yes
No
Made threatening statements in writing?
Yes
No
Implied that they may have a plan for violent or suicidal behavior?
Yes
No
Implied that they have identified a target for violence?
Yes
No
Been destructive to property?
Yes
No
In order to process the questionnaire, please provide the information requested below, all fields marked with
are required fields.
First Name:
Last Name:
Street Address:
City:
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Nigeria
Niue
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Tajikista
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State:
Select a State
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Tennessee
Texas
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Washington
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Province:
Zip / Postal Code:
E-mail Address:
Child's Name:
Child's Gender:
Female
Male
Child's Age:
Child's Grade in School:
Are you looking to enroll your child in a program:
Immediately
Within one week
Within 30 days
Undecided
Primary Phone:
Alternate Phone:
How did you hear about us?
Choose one:
Educational Consultant
EAP/Insurance
Hospital/Doctor
Internet Research/Web Search
Previous Parent/Alumni
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Public Agency/Court-Referred
School
Therapist/Clinical Professional
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If a specific person referred you to our programs, please let us know their name: