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Please answer the following questions so we may locate the best services for you.

What is your date of birth? * What is their date of birth? *

This is required.

What language do you prefer to use? * What language do they prefer to use? *

This is required.

Do you have insurance? * Do they have insurance? *

Name of Insurance Company *

This is required.

Do you have parental consent? *

Yes

This is required.

Are you filling assessment for yourself or your minor child? *

Self

Minor

This is required.

Are you the parent or legal guardian? *

Yes

This is required.

What is your gender? * What is their gender? *

This is required.

Parent/Guardian details:

First name: *

This is required.

Last name: *

This is required.

What is your date of birth? *

This is required.

Relationship with minor. *

Parent

Legal Guardian

This is required.

Minor child details:

First name: *

This is required.

Last name: *

This is required.

What is your child’s date of birth? *

This is required.

What is your child’s gender? * What is their gender? *

This is required.

For each question, select whether or not you or your minor child have been affected by each problem during the past TWO (2) WEEKS.

1. I have stomachaches, headaches or other aches and pains and I’m worried about my health or getting sick?

Yes

2. I’ve been bothered by not being able to fall asleep or stay asleep, or by waking up too early?

Yes

3. I’ve been bothered by not being able to pay attention in class or doing homework or reading a book or playing a game?

Yes

4. I’ve had less fun doing things than before or felt sad or depressed for several hours?

Yes

5. I’ve felt more irritated, angry or easily annoyed than usual or lost my temper more than usual?

Yes

6. I’ve felt nervous and anxious, been unable to stop worrying, or not been able to do things I wanted to or should do because I felt nervous?

Yes

7. I’ve started lots more projects than usual, done more risky things than usual or slept less but still had more energy than usual?

Yes

8. I’ve had thoughts that kept coming into my mind that I would do something bad or that something bad would happen to me or to someone else or I’ve felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off or I’ve been worried a lot about things I touched being dirty or having germs or being poisoned or felt I’ve had to do things in a certain way, like counting or saying special things, to keep something bad from happening?

Yes

9. I’ve heard voices—when there was no one there—speaking about me or telling me what to do or saying bad things to me, or had visions when I was completely awake—that is, seen something or someone that no one else could see?

Yes

10. I have had an alcoholic beverage?

Yes

11. I have smoked, snuffed or chewed a tobacco product?

Yes

12. I have used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), methamphetamine (like speed), or used any medicine without a doctor’s prescription to get high or change the way I feel?

Yes

13. I’ve experienced something disturbing (such as witnessing or experiencing a traumatic event like abuse, murder, torture, a natural disaster or another distressing event where I perceived that I or someone else were in grave danger), and I have frequent nightmares and other distressing symptoms that affect my sleep, attention, day and or quality of life?

Yes

14. I have had thoughts or attempts to hurt myself?

Yes

15. I have had thoughts or attempts to hurt someone else?

Yes

16. I have a family member who is addicted to drugs or alcohol, and I would like to connect with a support group of other family members struggling with the same thing?

Yes

17. I am having difficulty in relationships with family (siblings and caregivers)?

Yes

18. I have been forced to work and/or perform sexual acts for little to no money and against my will. I would like to receive support in getting out of this situation and building a life outside of these circumstances. Or, I have engaged in sexual activity (stripping, posing sexually for pictures or videos, oral sex, hand job, intercourse, escort services, lap dancing, or prostitution) in return for something (food, money, a place to stay, drugs, clothing, jewelry, favors, gifts, toys, medical assistance, promises to resolve legal issues, employment, travel, safety/protection, to avoid arrest)?

Yes

19. I have been to an inpatient psychiatric hospital 1 or more times and/or I have had an interaction with the department of juvenile justice and/or I have had an interaction with the department of Children and families?

Yes

20. I identify as Lesbian, Gay, Transgender, Queer or Questioning, Intersex, Asexual or Agender (LGBTQIA+), and would like to work with an LGBTQIA+ affirmative therapist, support group and/ or psychiatrist for mental health support?

Yes

21. I identify as Transgender, Gender Non-Binary or another gender that does not match my sex, and I would like to receive an evaluation and medical support for gender confirmation therapies (i.e. hormone replacement therapy, gender re-assignment surgeries, etc.)?

Yes

The following questions ask about things that might have bothered you. For each question, select whether or not you have been affected by each problem during the past TWO (2) WEEKS.

1. Feeling nervous, anxious, frightened, worried, on edge or feeling panicked or avoiding situations that make you anxious?

Yes

2. Little interest or pleasure in doing things or feeling down, depressed or hopeless?

Yes

3. Feeling more irritated, grouchy, or angry than usual?

Yes

4. Struggling to pay attention?

Yes

5. Sleeping less than usual, but still have lots of energy and starting lots more projects than usual or doing risky things than usual?

Yes

6. Unexplained aches and pains and feelings that your illnesses are not being taken seriously enough?

Yes

7. Problems with sleep that affected your sleep quality over all?

Yes

8. Thoughts of actually hurting yourself?

Yes

9. Thoughts or attempts to hurt someone else?

Yes

10. Hearing things other people couldn’t hear such as voices even when no-one was around or feeling that someone could hear your thoughts or that you could hear what another person was thinking?

Yes

11. Problems with memory (e.g. learning new information) or with location (e.g. finding your way home)?

Yes

12. Unpleasant thoughts, urges, or images that repeatedly enter your mind or feeling driven to perform certain behaviors or mental acts over and over again?

Yes

13. Feeling detached or distant from yourself, your body, your physical surroundings or your memories?

Yes

14. Not knowing who you really are or what you want out of life or not feeling close to other people or enjoying your relationships with them?

Yes

15. Drinking at least 4 drinks of any kind of alcohol in a single day, and wanting to reduce or discontinue drinking?

Yes

16. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco, and wanting to reduce or discontinue smoking?

Yes

17. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts of longer than prescribed [e.g. painkillers (like Vicodin), stimulants (like Ritalin or Adderall), (sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marihuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?

Yes

18. I experienced or witnessed a disturbing event, and as a result I have frequent nightmares, obtrusive thoughts or other negative symptoms that disrupt sleep, attention, day and or quality of life?

Yes

19. I am experiencing conflict in my relationship with a significant other or spouse, and I would like help to address this?

Yes

20. I have difficulty managing appointments, communicating to providers what I am struggling with, managing my finances and insurance benefits and other important life matters?

Yes

21. I have a family member who is addicted to drugs or alcohol, and I would like to connect with a support group of other family members struggling with the same thing?

Yes

22. I am a survivor of domestic violence; and/or I have concerns because I have been physically harmed, insulted and/or talked down to, threatened with harm or screamed and cursed at by my partner; and I would like help and support to address these challenges ?

Yes

23. I have been forced to work and/or perform sexual acts for little to know money and against my will. I would like to receive support in getting out of this situation and building a life outside of these circumstances. OR I engaged in sexual activity (stripping, posing sexually for pictures or videos, oral sex, hand job, intercourse, escort services, lap dancing, or prostitution) in return for something (food, money, a place to stay, drugs, clothing, jewelry, favors, gifts, toys, medical assistance, promises to resolve legal issues, employment, travel, safety/protection, to avoid arrest) before my 18th birthday, or with another person or persons arranging the exchange?

Yes

24. I identify as Lesbian, Gay, Transgender, Queer or Questioning, Intersex, Asexual or Agender (LGBTQA+), and would like to work with an LGBTQA+ affirmative therapist, support group and/ or psychiatrist for mental health support ?

Yes

25. I identify as Transgender, Gender Non-Binary or another gender that does not match my sex, and I would like to receive an evaluation and medical support for gender confirmation therapies (i.e. hormone replacement therapy, gender re-assignment surgeries, etc.)?

Yes

26. I am the parent of a child who identifies as Lesbian, Gay, Transgender, Queer or Questioning, Intersex, Asexual or Agender (LGBTQIA+), and I would like to receive support on how to accept this?

Yes

27. I would find it helpful to be connected to a supportive community of parents experiencing struggles related to caring for a child with emotional and behavioral health needs?

Yes

The following questions ask about things that might have bothered your minor child. For each question, select whether or not your minor child has been affected by each problem during the past TWO (2) WEEKS.

1. Complained of stomachaches, headaches or other aches and pains and worried about their health or getting sick?

Yes

2. Been bothered by not being able to fall asleep or stay asleep, or by waking up too early?

Yes

3. Been bothered by not being able to pay attention in class or doing homework or reading a book or playing a game?

Yes

4. Had less fun doing things than before or felt sad or depressed for several hours?

Yes

5. Felt more irritated, angry or easily annoyed than usual or lost temper more than usual?

Yes

6. Felt nervous, anxious, unable to stop worrying, or not been able to do things they wanted to or should do because they felt nervous?

Yes

7. Started lots more projects than usual, done more risky things than usual or slept less but still had more energy than usual?

Yes

8. Had thoughts that kept coming into their mind that they would do something bad or that something bad would happen to them or to someone else or they felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off or they worried a lot about things they touched being dirty or having germs or being poisoned or felt they had to do things in a certain way, like counting or saying special things, to keep something bad from happening?

Yes

9. Heard voices—when there was no one there—speaking about them or telling them what to do or saying bad things to them, or had visions when they were completely awake—that is, seen something or someone that no one else could see?

Yes

10. Had alcoholic beverages?

Yes

11. Smoked, snuffed or chewed a tobacco product?

Yes

12. Used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), methamphetamine (like speed), or used any medicine without a doctor’s prescription to get high or change the way they feel?

Yes

13. My child experienced something disturbing (such as witnessing or experiencing a traumatic event like abuse, murder, torture, a natural disaster or another distressing event where they or someone else were perceived to be in grave danger), and has frequent nightmares or other distressing symptoms that disrupt sleep, attention, day and or quality of life?

Yes

14. My child experienced sexual abuse, and has frequent and distressing symptoms that disrupt sleep, attention, day and or quality of life?

Yes

15. My child has had thoughts or attempts to hurt them self?

Yes

16. My child has had thoughts or attempts to hurt someone else?

Yes

17. My child has a family member who is addicted to drugs or alcohol, and they would like to connect with a support group of other youth experiencing the same thing?

Yes

18. My child is experiencing emotional and behavioral health challenges, and I am having difficulty managing their appointments, understanding what services would be best for them, navigating the mental health system, communicating to providers about what they’re struggling with, working with the school to develop a 504 or IEP plan and managing their insurance benefits and or other important life matters?

Yes

19. My child is experiencing significant emotional and behavioral health challenges that are causing problems at home or school and/or the community and they are involved in two or more systems such as a school 504 or IEP plan, teen court or other juvenile justice program, arrest or civil citation, contact with or supervision of services from Department of Children and Families, general mental health services (Counseling, medication, hospitalization, etc.), and my family needs help coordinating their care?

Yes

20. My child has difficulty in relationships with family (siblings and caregivers)?

Yes

21. I am concerned because my child runs away frequently, seems to have older friends, has money, clothing, new hairstyles, makeup, or other gifts etc. and I do not know how my child obtains those items; or my child is frequently connecting with adults thought social media sites; or my child is having sex with individuals that are 4 or more years older or are adults, has had sexually transmitted diseases, pregnancies etc?

Yes

22. My child has significant emotional, substance use and/ or behavioral health challenges; they are at risk for out of home placement; and they have been to an inpatient psychiatric hospital 1 or more times and/or they have had an interaction with the department of juvenile justice and/or they have had an interaction with the department of Children and families. My family is need of intensive and comprehensive in-home therapeutic services to help us prevent out of home placement?

Yes

23. My child has been prescribed Psychiatric medication and needs medication management and or a psychiatric re-evaluation?

Yes

24. My child identifies as Lesbian, Gay, Transgender, Queer or Questioning, Intersex, Asexual or Agender (LGBTQIA+), and would like to work with an LGBTQIA+ affirmative therapist, support group and/ or psychiatrist for mental health support ?

Yes

25. My child identifies Transgender, Gender Non-Binary or another gender that does not match their sex, and they would like to receive an evaluation and medical support for gender confirmation therapies (i.e. hormone replacement therapy, gender re-assignment surgeries, etc.)?

Yes

26. My child identifies as Lesbian, Gay, Transgender, Queer or Questioning, Intersex, Asexual or Agender (LGBTQIA+), and I would like to receive support on how to accept this?

Yes

27. I would find it helpful to be connected to a supportive community of parents experiencing similar struggles related to caring for children with emotional and behavioral health challenges?

Yes

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