Get-Started For Teen Please answer a few question for us, to connect you with the right therapist. Get-Started For Teen Name * Email * Phone * Who is filling out the form? * Teen (myself) Parent Family member What type of mental health services are you looking for? (For parent and family member) * I want therapy for my child I want parental advice Both What is the gender of the child?/ What is your gender? * Male Female Non-binary I don't know Prefer not to say What are the key areas you would want to work on?What is the child’s age? / What is your age? * 14 15 16 17 18 19 Has the child been in therapy before?/ Have you been to therapy before * Yes No How would you rate the child’s mental health?/ How would you rate your mental health? * (1 to 2) Currently not feeling distressed (3 to 4) Sometimes feels distressed (5 to 6) Regularly feels distressed (7 to 8) Often feels distressed (9 to 10) Constantly feeling stressed Which mental health concerns is the child experiencing?/ Which mental health concerns are you experiencing? * Experiencing depressive feelings Feeling anxious/ overwhelmed Feeling irritated Issues with exploring my identity Grief Trauma Low self-esteem/ low self confidence Peer pressure Bullying Self Harm Academic Pressure Suicidal Ideation Conflicts with parents Conflicts with friends (Only for parents) What are the current signs that you have observed in the child? * Changes in eating habits Notable changes in sleep Poor academic performance Loss of interest in activities Withdrawing from loved ones Signs of self harm Not communicating their problems Difficulty concentrating Hyperactive behaviour If you are human, leave this field blank. Submit
