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 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.
Child's First Name:
Child's Middle Name:
Child's Last Name:
Optional, for demographic informational purposes only.
Hispanic or Latino
American Indian or Native Alaskan
Black or African American
Native Hawaiian or Other Pacific Islander
Caucasian or White
Name of Child's School
Child's Grade level
Parent or Legal Guardian's Name
City, State, and Zip Code:
Contact Phone Number:
Other Contact Phone Number:
How would you like to be contacted?
Can we leave a message?
If your child is currently under the care of a Physician, please state the Physician's name and contact number.
Please list any prescription medication your child is currently taking.
Do you or your child have any physical limitations?
Source of Payment:
Funding is provided for children (17 and under) who are determined to be eligible for the CHAT program. Please list any other sources of Payment you currently have.
Insurance (Please list insurance company under "other")
Partnership to Health
How did you hear about us?
One Safe Place
Family Dynamics brochure or website
Please check any and 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
Increased appetite or weight gain
Crying a lot
Irritable or angry
change in sexual 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 the trauma
Afraid to leave home or go places
The following questions apply to the child's behavior.
I feel like I need to leave when I am in a crowded room
Violent behavior or 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
Has your child experienced or witnessed any of the following:
Check any or all that apply.
Domestic or Family Violence (including high conflict divorce or separation)
Child Endangerment (including parental substance abuse)
School or Community Violence (including bullying)
Child Abduction (including that by a non-custodial parent/guardian)
Community hate crimes and acts of terrorism
Has the child experienced a recent change in their life?
death of a loved one
Is English your primary language?
Can you read and write in English?
If English is not your primary language, do you need an interpreter?
ASL (American Sign Language)
Do you need help with transportation for services?
Office Use Only
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