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Home
Counselors
Services
Resources
Schedule
Counseling for a sound mind | sound life.
Tell us about your Teen.
Has your teen been to counseling before?
Yes
No
What is their weekday availability?
Check all that could work.
Mornings (9am - 12pm)
Afternoons (12pm - 5pm)
Evenings (5pm-6pm)
What specific concerns or issues have prompted you to seek counseling for your teenager?
*
Check all that apply.
Anxiety or excessive worry.
Depression or persistent sadness.
Academic difficulties.
Social isolation or withdrawal.
Peer conflicts or bullying.
Behavioral problems or aggression.
Grief or loss.
Family changes (e.g., divorce, relocation).
Trauma or significant life event.
Self-esteem or self-image concerns.
Substance abuse or addiction.
Other
How long have these concerns been present?
*
-
A few weeks.
A few months.
Over six months.
Over a year.
Not sure.
Share with us your family Dynamic.
-
Nuclear Family (Parents and Children)
Single-Parent Household
Blended Family (Stepfamily)
Extended Family (Grandparents, Aunts, Uncles, Cousins)
Foster or Adoptive Family
Other
How is your teenager's academic performance?
*
-
Excellent (Consistently high grades and achievements)
Good (Above-average performance with occasional challenges)
Satisfactory (Average performance with some room for improvement)
Below Average (Struggling with grades and learning)
Not Applicable (e.g., not currently attending school)
Describe your teenager's social life and relationships with peers.
*
-
Strong and Supportive Friendships
Average Social Life with No Major Concerns
Difficulties Making or Maintaining Friendships
Peer Conflict or Bullying Issues
Social Isolation or Loneliness
Are there any physical health concerns or chronic illnesses that may be affecting your teenager's well-being?
*
-
No, no physical health concerns or chronic illnesses.
Yes, a known chronic illness (Please specify below).
Yes, occasional health issues (Please specify below).
Please specify health concerns.
Are there any coping mechanisms that you believe may be unhealthy or concerning?
-
No, all coping mechanisms seem healthy.
Yes, using substances (e.g., alcohol, drugs).
Yes, isolating themselves excessively.
Yes, engaging in self-harming behaviors.
Yes, aggression or violence.
Other
Not sure.
Describe any noticeable changes in your teenager's mood, behavior, or emotional well-being:
*
-
No significant changes observed.
Increased irritability or moodiness.
Withdrawal or social isolation.
Increased sadness or frequent crying.
Changes in eating or sleeping habits.
Changes in academic performance.
Expressing feelings of anxiety or worry.
Increased anger or aggression.
Other
What are your expectations for the counseling process, and what goals would you like to achieve for your teenager through counseling?
*
Is there any additional information or context you believe is important for the counselor to know?
Guardian's name
*
First Name
Last Name
Teens name
First Name
Last Name
How old is your teen?
Email
*
Phone
(###)
###
####
Thank you for sharing.
We will be in touch!
