Here is our pre-assessment form for parents. This form is essential for us to evaluate whether your child will be a good fit both for our program and also for the current milieu/census of teens in the program, and we use it to support in the development of an initial treatment plan. We also use this information to make the case to the insurance company for the medical necessity of a residential level of care. Because of this, it is important for you to answer these questions in as much detail as possible. When answering questions, whenever applicable, please:

  1. Include date ranges and date of last incident (especially for suicidal thoughts/speech, major depressive episodes, outbursts, aggression, self-harm, danger to self or others, etc…)
  2. Use multiple sentences: if the answer to a question is yes, we want as much info as possible. Previous treatment providers, programs, school contact info, etc… If you answer a yes question in less than two sentences, please add more.

Once we receive this form, we will review it and follow up with any additional, more specific questions. Once we’ve done that, the form will be submitted to our Clinical Director for review, and she will make the determination of suitability for our program. This can take up to a day. We will reach out to you as soon as we hear back regarding approval, and, if approved, will also discuss insurance benefits and coverage with you.

Thanks so much, and we look forward to working with you and your family.

  • Parent/Family Information


  • Date Format: MM slash DD slash YYYY
  • Client Information


  • Date Format: MM slash DD slash YYYY
  • Referral Information


  • Reason for referral: What made you call for treatment at this time? Chief Complaint and Symptoms (i.e. issues at home or school, symptoms, mood changes, changes in behavior etc.) For most families, the presenting issues have been in existence for some time so please describe what is happening now to make you seek out residential treatment.
  • Placement Information


  • Psychological History


  • Family History


  • Education Information


  • Medical Information


  • Important Contact Information


  • Insurance Information


  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance Information (if applicable):


  • Date Format: MM slash DD slash YYYY