CEDAR CREST HOSPITAL AND RESIDENTIAL TREATMENT CENTER
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Cedar Crest: Admissions - Online Assessment Form

Please complete the questionnaire to determine if your child might benefit from further evaluation and/or mental health counseling. All information is confidential. The information will be reviewed by a licensed professional counselor who will respond to you through your e-mail or home telephone.

Yes	No
		"Normal" discipline seems ineffective with my child.
		Arguments and conflicts are seemingly constant in our home.
		I am concerned about my child's choice of friends.
		Problems at school (academic, behavioral) are common.
		My child complains that nobody cares for him/her.
		Sometimes my child becomes so angry I worry about what might happen next.
		Conversations with my child quickly turn into arguments.
		My child seems to be dissatisfied with the way things are going.
		I have witnessed destructive behavior in my child.
		Routine things like eating and sleeping are a problem for my child.
		My child has exhibited cruelty to animals or other people.
		Communication between my child and me has come to a screeching halt.
		I believe that the threats my child makes are real and that he/she may be planning a violent episode.
		My child seems lost and is without purpose or direction.
		I have witnessed/suspect drug or alcohol use.
		It seems too easy for my child to take advantage of others.
		I am concerned over what I believe are depressive symptoms (sleeps excessively, drastic fluctuations in weight).
		My child has endured more stress than most kids have (trauma, divorce, death, assault).
		I am concerned about my child's sexuality (promiscuous, poor boundaries).
		My child says negative things about him/herself or others.
		My child talks or writes a lot about death and dying.

Please provide the following information so that we may appropriately process your self-assessment of your child. * Indicates required completion.
*First Name:
Last Name:
Mailing Address:
*City:
*State:
Zip Code:
Country:
Home Telephone:	( )
Work Telephone:	( )
*Email:
Contact:	Home Telephone Work Telephone E-mail
Child's Name:
*Child's Age:
*Child's Sex:	Male Female
Interest:
Comments:


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