Forms

PLEASE COMPLETE ALL required & REQUESTED FORMS

  • Bellow you will find a list of common challenges people face. Please check any that apply to you at present. Circle the three that bother you most at this point in time.
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  • SYMPTOM CHECKLIST: Read each item below and decide how much you think your child/adolescent has been showing the problem during the past month. (0 = Not at all 1 = Rarely 2 = Sometimes 3 = Often)
  • Family Mental Health History Check all that apply to biological family
  • If you responded “no” to both questions, you can STOP here. Thank you for providing us with this important information. If you responded “yes” to one or both questions, please complete the remaining questions:
  • CAGE‐AID Questions (to be completed by a child/adolescent age 12 and up)
  • The following is a list of common symptoms in individuals who are abusing alcohol or drugs.
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  • Minor’s Signature
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