Questionnaire Form – Helping Troubled Teens

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Helping Troubled Teens

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Questionnaire Form
FAQ

Name(Required)

First Last

Relationship(Required)

Other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cellular Phone(Required)

Fax Number

Email(Required)

Section Break

Teen Information(Required)

First Last

Gender(Required)

Male

Female

Date Of Birth (DOB)(Required)

MM slash DD slash YYYY

Age(Required)

Areas of Concern (check all that apply)(Required)

Depression

Defiant

Bi-polar Disorder

ADD/ADHD

Failing in school

Skipping School

Rebellious at home or school

Destructive behavior

Lack of accountability for choices

Runaway or curfew Issues

Schizoaffective Disorder

Oppositional Defiant Disorder

Sexual Deviant Disorder

Cutting Disorder

Pyromania Disorder

Teen Sleeping Disorder

Mood Disorder

Cheating

Stealing

Suicide attempts

Accelerated schooling

Anger towards parents or authority figures

Refusing to follow family rules

Drug and/or alcohol use/abuse

Behavioral issues

Low self esteem

Sexually active

Bad peer group

Drastic mood swings

Eating Disorder

Pregnancy

Post-Traumatic Stress

Narcissism

Kleptomania

Self mutilation

Personality Disorder

Anxiety

Dishonesty

Psycho-sexual Disorder

Lying

Talk of suicide

Psychological Additions

Check the program(s) You are interested in(Required)

All Girl programs

All Boy Programs

Coed Programs

Private Schools

ADHD Treatment

Boarding Schools for Troubled Teens

Residential Treatment figures

Wilderness Programs

Military Schools/Boot Camps

International Programs

Intensive Psychiatric Care

Sexually active

Please share your specific comments and concerns about your teen

Troubled Teens Programs - Professional Help for Troubled Teens