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I'd like to:

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 13 and under 14 15 16 17 18 and over Parent/guardian's Name Parent/guardian's Phone Number Comments:

How can we help?

PMB C18
9101 W. Sahara Ave. Suite 105
Las Vegas, Nevada 89117
United States

TEL  702 233 0444
FAX  866 319 3572

info@coralreefacademy.com

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Coral Reef Academy
is a member of

The National Association of Therapeutic Schools and Programs (NATSAP) serve as a national resource for programs and professionals assisting young people beleaguered by emotional and behavioral difficulties.