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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 (i.e. sad, angry, withdrawn, etc.)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: • Country: State: • Province: • Zip / Postal Code: E-mail Address: • Child's Name: Child's Gender: Child's Age: • Child's Grade in School: Are you looking to enroll your child in a program: Primary Phone: • Alternate Phone: How did you hear about us? If a specific person referred you to our programs, please let us know their name:

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