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Troubled Teen Assessment Test

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 (i.e. sad, angry, withdrawn, etc.)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
Has your teen ever been verbally abusive?
Yes No
Do you find yourself picking your words carefully when speaking to your teen so as not to elicit a verbal attack or rage?
Yes No
Are you worried that your teen may not finish high school?
Yes No
No matter what rules and consequences are established, does your teen defy them?
Yes No
Are you worried your teen may be sexually promiscuous?
Yes No
Does your teen seem to lack self-esteem and self-worth?
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:"
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:
Primary Phone:"
Alternate Phone:
How did you hear about us?
If a specific person referred you to our programs, please let us know their name:
   
 
 
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