Request for Child Therapy Services
You may enter your personal information here and a Family Dynamics CHAT representative will contact you for an appointment. The information you enter here is confidential, however, as with any electronic system, your information may not be secure. Select 'I agree' to indicate that you acknowledge the limitation of protection of your information.
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Select 'I agree' to continue *
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Child's first name *
Child's middle name
Child's last name *
Child's birthdate *
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Gender *
Child's Race
For demographic informational purposes only, this has no influence on services rendered.
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Name of Child's School *
Child's grade level *
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Parent or Legal Guardian Name *
Mailing address *
City, State, & Zip *
Would you prefer to be seen at out office in Shasta or Siskiyou County?
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Email address
Contact phone number *
Other contact phone number
How would you like to be contacted? *
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Can we leave a message? *
If your child is currently under the care of a physician, please state the physician's name and contact information.
If not, enter 'none'
Please list any prescription medication your child is currently taking *
Please include: type, strength, frequency, dosage. If none, enter 'none'
Do you or your child have any physical limitations? If so, please describe.
Source of payment *
If Partnership please type in Member ID #
Requesting a Male or Female therapist?
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How did you hear about us? *
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Please check all that apply: *
This is information about your child
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In what ways are these symptoms affecting your child's life? *
Behavioral Questionnaire *
The following questions apply to the child's behavior
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In what ways are these symptoms affecting your child's life? *
Has your child experienced or witnessed any of the following: *
Check any or all that apply
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Has the child experienced a recent change in their life (i.e. parental divorce, move, relocating schools etc.). Please describe. *
In what ways are these symptoms affecting your child's life?
Is English their primary language?
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Can your child read and write in English?
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If English is not your primary language, do you need an interpreter?
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Are you willing to attend Tele-Health Sessions via Zoom? *
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