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Last Name:
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First Name:
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Student Name:
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Best Time to Contact:
afternoon
Anytime is Fine
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evening
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Assess my child's need for placement
HOME
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The Program
- Child Assessment
Has your child or loved one…
Shown signs of substance abuse?
Yes
No
Had trouble dealing with anger and frustrations appropriately?
Yes
No
Displayed poor or dangerous decision making skills?
Yes
No
Had issues with school or educational ventures?
Yes
No
Had issues in their family structure?
Yes
No
Dealt with a traumatic event recently or in the past 2 years?
Yes
No
Displayed signs of depression?
Yes
Had legal issues as a result of their current behavior?
Yes
No
Had suicidal ideation or attempts in the past year?
Yes
No
Child's Name
Select child's age
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