Request for Appointment for Child by Parent
You may enter your personal information here and a Family Dynamics Representative will contact you for an appointment. The information you enter is confidential, however as with any electronic systems, your information may not be secure. Select (I Agree) to indicated that you acknowledge the limitation of protection of your information.
Select " I Agree" and continue.
CHILD'S FIRST NAME
CHILD'S MIDDLE NAME
CHILD'S LAST NAME
Parent requesting Referral
City, State and Zip Code
Contact Phone Number
Other contact numbers
How would you like to be contacted
check all that apply
Source of Payment
How did you hear about us?
One Safe Place
Family Dynamics brochure
DOES YOUR CHILD HAVE A PRIMARY PHYSICIAN?
If yes, who is your child seeing?
What medications is your child currently taking?
(Please include all supplements)
The following information is optional.
This information may help us serve you better.
Check all that apply
This is information about your child.
Feelings of hopelessness
Lack of energy or can't get out of bed
Lack of enjoyment
Feelings of sadness or emptiness
Loss of appetite or weight loss
Increase appetite or weight gain
Crying a lot
Irritable or angry
Change in sexual interest/behavior
Rapid heart rate
Sudden feelings of panic
Feeling like you can't breathe
Experienced a traumatic or life threatening event
Flashbacks or Feeling like the event is happening over again
Avoiding activities associated with trauma
Afraid to leave home or go places
The following items are associated with behavior
I feel like I need to leave when I am in a crowed room
Violent behavior -- Excessive anger
Binge eating or restricting food
Unable to relax
Thoughts of hurting yourself
Thoughts of hurting others
Sexual behavior problems
Feeling like I am out of control
Substance abuse history
Please indicate past or current substance abuse history
Abused medications prescribed to me
How frequently used?
How much did you use?
When was last time you used?
Was there a change in their life recently?
Move, parents separating, a divorce etc?
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(If not a field that is required will show in red please go back through form & fill out then re-submit)
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