JUNIOR PROGRAMME SUITABILITY ASSESSMENT
7-17 year olds. To be completed by parent or guardian prior to telephone consultation with a Specialist.
Please complete all questions and press submit. This will be sent to a Linden Method Support Specialist who will then be in touch advising how we might be able to help you and your child.
We abide by GDPR data protection laws and respect yours and your child's privacy and all information is held in the strictest of confidence. This information is not shared with any third parties and will be securely destroyed after the telephone consultation if you do not join the program. If you join the program the information may be retained for the duration of the support period (12 months).
You have a right to request any information that is stored by us, at any time, by sending a Subject Information Request to email@example.com
Parent/Guardian email address
Child's year of birth
Country of Residence
Phone including area code
Confirm your email address
Please be as honest as you can with your answers - This information will not be divulged to a third party.
If you reside in the UK is your child currently under CAMHS? If outside of the UK, any other mental health organisation? Please give details.
How long has your child suffered from anxiety?
Has your child received other therapy (for example, CBT?) If yes, please give details of the type of therapy, approximate dates and length of therapy.
Prior to lockdown due to Covid 19, was your child
able to attend school?
Expressed as a percentage, how much of their spare time is spent in their bedroom, (isolated from the rest of the family)
Do you, or any other members of the family suffer (or have suffered) with an anxiety condition?
Child's Symptoms and Behaviours
We appreciate that you may not be aware of every symptom they are experiencing, so please just tick those you know about.
What symptoms of anxiety does your child experience?
Generalized Anxiety Disorder
Monophobia (fear of being alone)
Emetophobia (fear of vomiting)
OCD (Obsessive Compulsive Disorder)
Post Traumatic Stress Disorder
Social Anxiety Disorder
Pure O (Inappropriate thoughts)
Night-time panic attacks
Fear of dying
Has your child ever suffered from an eating disorder. If so, please give more details and state whether they have ever been hospitalised and if so, for how long and when?
Has your child been diagnosed with any other 'conditions', such as Aspergers, ADHD, etc?
(We don't like giving children 'labels' as we feel they are labelled too readily these days, but we have to ask the question).
Please identify which are the most overwhelming symptoms or conditions.
Does your child take prescription medication for their anxiety?
Does your child suffer from diabetes or other endocrine disorders?
Has your child ever been diagnosed with clinical depression?
Has your child ever been diagnosed with a psychosis?
How influential is anxiety in their life?
It is ruining their life
It is a constant negative influence
It impairs everything they do
They need to get rid of it fast
It doesn't stop them doing things
It is constant but not catastrophic
It doesn't really bother them too much
And finally, are there any recent or ongoing issues that you are aware of that your child is dealing with (for example, bullying, bereavement, family separation, etc.)
Please write anything in the box above that you feel might be relevant to your child's condition.
Your assessment will be handled by an accredited Anxiety Recovery Expert.