In order to process the questionnaire, please provide as much of the following information as possible. All fields with are required fields.

 
HR
 
 How did you find us? 
 
 What browser are you using? 
 
 Parent/Guardian Name:
 
 Address:
 
 City, State, Zip:
   
 
 Telephone:
 
Fax:
 
 Email:
 
Social Security Number:
 
Primary Insurance Provider:
 
HR
 

Please answer the following questions as completely as possible. This will help us to better assess your daughter's needs.
 

 Student's First Name:
 
 Student's Age: 
 
Student's Birthdate:  mm/dd/yyyy
 
Relationship to Child:
        Parent         Friend of Family
        Relative         Other
       If Other, please describe: 
 
Please Describe The Problems You Are Having:
(Please limit to 500 characters)
 
Previous Treatment or Placement:
(Please limit to 500 characters)
 
Has the student been diagnosed by a mental health professional?  
        Yes    No
       If yes, what is the diagnosis?  (Please limit to 500 characters)
 
Is the student currently on any medication?    Yes    No
       If yes, what medications?  (Please limit to 500 characters)
 
Major Issues:
(Please limit to 500 characters)
 
Are you currently working with Working Professional?     Yes    No
       If yes, who? 
 
Comments/Suggestions:
(Please limit to 500 characters)


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