Adolescent Counseling Contact Form
(PLEASE CHECK ALL THAT APPLY TO YOUR CURRENT SITUATION)
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Parent/Caregiver's Name: *
Contact Number: *
Contact Email: *
Adolescent's Name: *
Is Your Adolescent Experiencing Any of the Following:  (Please Answer All Areas of Concern) *
Yes
No
Academic Underachievement
Adoption
Anger Control Problems
Anxiety
Attention-Deficit/Hyperactivity (ADHD)
Autism Spectrum Disorder
Bipolar Disorder
Blended Family
Conduct Disorder/Delinquency
Divorce Reaction
Eating Disorder
Grief/Loss Unresolved
Intellectual Development Disorder
Low Self-Esteem
Medical Condition
Negative Peer Influences
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant Disorder
Overweight/Obesity
Panic/Agoraphobia
Parenting
Peer Sibling Conflict
Physical/Emotional Abuse Victim
Posttraumatic Stress Disorder (PTSD)
Psychoticism
Runaway
School Violence Perpetrator
Sexual Abuse Perpetrator
Sexual Abuse Victim
Sexual Identity Confusion
Sexual Promiscuity
Social Anxiety
Specific Phobia
Substance Use
Suicidal Ideation
Unipolar Depression
What Health Plan Does Your Adolescent Participate In? *
If Other or Multiple Health Plans, Please List Below:
What is Your Adolescent's Preferred Availability?                                    (PLEASE LIST DAYS & TIMES) *
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