Free Information Packet
Please complete this free evaluation:

Adolescent Name (required):
Date of Birth:
Parent Name (required):
Address:
City State Zip:
Phone 1:
Phone 2:
Email (required):

Depression:			Thoughts of hurting themselves:
Low energy:			Thoughts of hurting someone:
Low self esteem:			Thoughts racing:
Poor concentration:			Sadness or loss:
Hopelessness:			Stress:
Worthlessness:			Anxiety or panic:
Guilt:			Heart pounding or racing:
Sleep increase or decrease:			Chest pain:
Appetite increase or decrease:			Trembling or shaking:
Sweating:			Sexual abuse issues:
Tingling or numbness:			Confusion or unclear thinking:
Delusions or hallucinations:			Fear of dying:
Fear of going crazy:			Excessive behaviors:
Nausea:			Nervousness:
Phobias:			Fatigue:
Obsessive or compulsive:			Loneliness:
Nightmares:			Feelings they are not real:
Headaches:			Feelings things are not real:
Difficulty trusting:			Lose track of time:
Poor impulse control:			Recurring unpleasant thoughts:
Family problems:			Anger or frustration:
Difficulty relaxing:			Easily agitated or annoyed:
Sexual problems:			Defies rules:
Stomach problems:			Blames others:
Pain:			Excessive use of drugs or alcohol:
Relationship problems:			Use of prescription medications:
Bowel problems:			Blackouts:
Bladder control problems:			Physical abuse issues: