Child Intake

Please correct the errors described below.
It is your responsibility to inform Northwest Counseling of changes in address, phone #, and insurance coverage.
Please note: Email correspondence is not considered to be a confidential medium of communication. WE do have HIPPA compliant emails at Northwest Counseling.
Please specify if any of the milestones were not met on time

Please complete the following if your child is within the ages of 6-17. All questions should be answered for symptoms seen within the past 2 weeks Scale is 0 (none, not at all) 1 (Slight, rare less than a day or two) 2 (Mild, Several days) 3 (Moderate, More than half the days) 4 (Severe, nearly every day)
Copyright © 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.

Severity Measures for Children Ages 11-17 Please have child complete. All answers should be symptoms experienced within the past 7 days.

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