| School History (year/grade and reason for move or change) | |
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| Please List any academic struggles and any extra support being provided | |
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| Please list any helping professionals that you have been involved with in an effort to help your child | |
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| How would you describe your child’s presenting difficulties? | |
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Duration of symptoms |
| Mild | |
| Moderate | |
| Severe | |
| What signs and symptoms have you noticed? | |
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| Is there a history of self harm, (cutting, eating disorder, suicidal thoughts or attempts?) | |
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| How would you describe your child’s social/emotional adjustment? | |
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| How would you describe your Child’s Peer relationships? | |
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| Is there a history of bullying, if so please describe? | |
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| Involvement in extracurricular activities | |
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| Please list how you hope the treatment will help | |
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Electronic Communication The use of electronic communication is used primarily for the purpose of billing and coordinating contact. The transmission of information via email or text may unintentionally limit the protection of confidentiality. More specifically, networks are not secure, emails are not encrypted and emails can be sent to unintended recipients without the sender’s intent. Given these risks, I agree to use email to communicate for billing and the purpose of coordinating contact. |
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