ASSESSMENT TEST

Please complete the following questionnaire to determine if your child
may need placement services.All information submitted is confidential.
The results will be displayed upon pressing the submit button.

Has your troubled teen had recurring problems due to.. Any traumatic events or changes in his /her life? (i.e. abuse, divorce, death,etc.) Yes No Inability to manage anger Yes No Within the last six months, has your trouble teen: Had any changes in behavior and / or mood? (i.e. sad, angry, withdrawn, etc.) Yes No Exhibited depressive symptoms? (i.e. weight loss, weight gain, excessive sleep, etc.) Yes No Has problems getting along with others? Yes No Do you suspect that your troubled teen has been abusing drugs or alcohol? Yes No Has your troubled teen disregarded family rules and parental guidance? Yes No Has you troubled teen been able to escape consequences due to the ability to manipulate people and situations? Yes No Had problems in school? (i.e. poor grades, challenging authority, etc.) Yes No Intentionally frightened others? Yes No Made threatening statements in writing towards you or others? Yes No Implied that they may have a plan for violent or suicidal behavior? Yes No Implied that they have identified a target for violence? Yes No Been destructive to property? Yes No Step 2: In order to process the questionnaire, please provide the information requested below, all fields marked with • are required fields. First Name:• Last Name:• Street Address: City:• State:• (2 Letter State Abbreviation) Zip / Postal Code: Country / Province: E-mail Address:• Child's Name: Child's Gender:• Female Male Child's Age:• Child's Grade in School: Step 3: Please complete the following questionnaire to determine if your troubled teen may need placement services. All information submitted is confidential. The results will be displayed upon pressing the Process Questionnaire button. Are you looking to enroll your teen in a program: IMMEDIATELY WITHIN ONE WEEK WITHIN 30 DAYS UNDECIDED Primary Phone:• Alternate Phone: How did you hear about us? Choose one: Educational ConsultantEAP/InsuranceHospital/DoctorInternet Research/Web SearchPrevious Parent/AlumniPrint AdvertisementPublic Agency/Court-ReferredSchoolTherapist/Clinical ProfessionalTelevisionRadioWeb Advertisement If a specific person referred you to our programs, please let us know their name:         Troubled Teen Transports (getting your troubled teen to the program) | Articles | Boarding Schools Troubled Teens Resources | Privacy Policy   ©Copyright 2006 BoardingSchools-TroubledTeens.Info. All Rights Reserved Website by Hybrid Design