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Assessment
3 STEP ASSESSMENT
Our assessment provides us a better understanding of your child's treatment needs
I
nformation you provide will be confidential and handled professionally
Step 1: Education
Child's current level of education
Middle School 12-14yrs old
High School 15-17yrs old
Is your child passing/failing school currently?
Passing
Failing
Is your child truant?
Yes
No
Have you inquired about additional programs/resources to help your child?
Yes
No
STEP 2: SOCIAL AND INFLUENCES
Have you noticed a change in your childs peer group/friends?
Yes
No
Are you aware of your childs social media habits?
Yes
No
Is your child using drugs?
Yes
No
IF YES [DU]
STEP 3: Family Dynamic
Parents
Married
Divorced/Seperated
Child is my...?
Biological child
Adopted child
I am their legal guardian
SIBLINGS
Single Child
Brothers and Sisters
Blended Family
Has there been a family crisis?
Yes
No
IF YES [FC}
Which best describes your Fundng Options
Private Insurance
Out of Pocket
Other Funding Source
Help me find Financing Options
First Name
Last Name
Best Number to Call with Results
Email
I agree to the terms & conditions
SUBMIT ASSESSMENT
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