EmailMe Form - Request Services

Name

First Last

Child's Name

First Last

Child's Age

Email *

Phone

### - ### - ####

How would you prefer to be contacted?

Email

Phone

No Preference

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Please describe the concerns you have for your child that have led you to consider residential treatment in as much detail as possible.

Please describe any stressful events that have occurred in your child's life, such as family troubles (ie. divorce, death of a loved one, family conflict), difficulties with peers (ie. bullying, social isolation), medical issues, abuse (ie. physical, emotional, or sexual abuse/assault), and other trauma (ie. homelessness, surviving a natural disaster).

Please detail any mental health or substance abuse services that your child is currently receiving, as well as anything you have previously tried in order to help your child. If your child has received any mental health diagnoses, please list them and clarify whether you and your child agree with each diagnosis. If your child has been hospitalized for mental health reasons, please list the dates of hospitalization(s) and circumstances that led to hospitalization(s).

Please list any prescription medications, over-the-counter medications and vitamins/supplements that your child is taking or has recently stopped taking for medical or psychiatric reasons. If possible, please include dosages and dates started/stopped/increased and any corresponding side effects or behavioral changes.

Does your child know that you are considering residential treatment and, if so, how does she feel about that?

Health Insurance Company/Plan (please write "None" if your child is uninsured)

If you choose to hire me and I agree to work with your family, please check each box that you will agree to.

I will actively work with you to create the best plan for my child, and agree to return all calls and e-mails from you within 24 hours, except in case of an emergency.

I will allow you to speak to my child by phone without my supervision, unless my child's preference is for me to take part in calls.

Do you have any questions for me?