Request for Service

Request for SErvice

Please complete on behalf of the client
Client's Name*

First NameLast Name
Client Date of Birth

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Date
Client Gender
Your name*

First NameLast Name
Address

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Your contact*

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Please tell us who referred you?
Depressed moodRacing thoughtsExcessive worry, reassurance seekingUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncreased risky behaviorAvoidanceSchool Avoidance/RefusalRageHallucinationsConcentration/forgetfulnessDecreased need for sleepSuspiciousnessChanges in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spells and emotional labilityObsessive Compulsive DisorderBFRB (hair pulling/skin picking)HoardingPanicPANS/PANDASOther
Superbill for potential insurance coveragePrivate Pay - out of network
MondayTuesdayWednesdayThursdayFridayNot applicable
MondayTuesdayWednesdayThursdayFridayNot applicable
Early MorningAfternoonLate MorningEveningMid-Day
SPACE (Supportive Parenting for Anxious Childhood Emotions)Safe & Sound Protocol (SSP) listening therapyExposure Response Prevention (ERP)Animal-Assisted TherapyCognitive Behavioral Therapy (CBT)Not Applicable
IndividualSafe & Sound Protocol (SSP) listening therapyGroupBoth
Past medical problems, nonpsychiatric hospitalization, or surgeries
Psychiatric History:
YesNo
If yes, Please describe when, by whom, and nature of treatment
YesNo
If yes, Please describe when, by whom, and nature of treatment
Date

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Request for SErvice

Psychiatric History: