Assessment Form – Sierra Sage Treatment Center

Within the last six to twelve months, has your child: (Check All That Apply)*

Run away from home
Been defiant of family rules and parental guidance
Struggled to manage anger or irritability
Had significant changes in behavior or mood
Had unexplained money or items (phone, clothing, jewelry)
Had symptoms of depression, such as sudden weight loss/gain or excessive sleep
Shown signs of drug or alcohol use, including stealing, impulsive or irritable behaviors, sudden mood changes, excessive sleep
Problems attending school, poor grades or discipline issues at school
Broken items in the home on purpose or destroyed property
Intimidated or threatened parents or siblings
Made written or verbal statements they would harm themselves
Self-harmed to include cutting, burning, or scarring
Had a traumatic events in the family such as divorce, death, or natural disaster
Been the victim of a crime

Name*

Email*

Phone*