Daybreak

Contact

Schedule an Assessment

 
Name *
Name
Phone *
Phone
Child's Name *
Child's Name
Please tell us a little about your child:
Are they depressed or sad? *
Do they withdraw from the family? *
Have they stopped doing things they used to enjoy? *
Do they talk about suicide? *
Have they ever attempted suicide? *
Do they harm themselves intentionally? *
Have they ever harmed anyone else? *
Have they ever been abused or neglected? *
Are they anxious or nervous? *
Anxious or nervous about school? *
Anxious or nervous about leaving the house? *
Anxious or nervous about being separated from you? *
Have they ever had a panic or anxiety attack? *
Does your child accept consequences and responsibility for their actions? *
Is your child cooperative at home? *
Has your child ever runaway from home? *
Have they ever runaway from school? *
Please tell us about school:
Do they get in trouble at school? *
Have they ever been suspended? *
Do they often call to come home early? *
Are they often tardy? *
Additional Information
 

Do not use this form to seek emergency help for your child. If this is a medical emergency, call 911. If your child is expressing suicidal and/or homicidal thinking or planning-call your current outpatient therapist, 911, or transport your child to the closest emergency room for an evaluation.