Outpatient Assessment - Ages 6 to 17

Parent / Guardian Form

This Assessment form is to help our Clinicians better understand the situations regarding your child. It is important to understand that this information is electronically delivered to a certified Clinician, and will not be shared with anyone without your prior consent. You will be contacted soon after completing this assessment to discuss Better Living Counseling Services outpatient therapy option.

Information regarding Client
Parent / Guardian information
Information about the person filling out Assessment
Parent / Guardian's Name *
Parent / Guardian's Name
Parent / Guardians contact phone number *
Parent / Guardians contact phone number
The questions below ask about things that might have bothered your child. For each question, select the option that best describes how much (or how often) your child has been bothered by each problem during the past TWO (2) WEEKS.
IN the past two weeks, has your child...

Assessment derived from DSM-5 Cross-Cutting Symptoms Measure.  Copyright ©2013 American Psychiatric Association. Material reproduced with permission