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home // patients & visitors // services // behavioral health // specialties // outpatient therapy // patient questionnaire

outpatient therapy referral questionnaire

This page is not frequently monitored. If your child is experiencing a mental health crisis, please call 911 or go to an emergency department.

Has the patient had outpatient counseling?
Has the patient had medication management?
Does the patient have a history or current Autism Spectrum Disorder (ASD) Diagnosis?
Does the patient have a history or current substance use disorder diagnosis?
Does the patient have a history or current oppositional defiance or conduct disorder diagnosis?
In the past three months, has the patient made any threats or attempts to hurt self or others?
In the past three months, has the youth tried to cause or has he/she caused physical injury (including sexual) to another person or against property?
Are there any current legal charges related to hurting others or the destruction of property?
Do you have concerns that the patient may hurt others during his/her treatment?
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