Name of the person completing this form *

First Name

Last Name

Phone number of the person completing this form *

(###)

###

####

What is the name of your child with ADHD? *

First Name

Last Name

Who plans to attend the Summer Workshop (check all that apply). *Note that the parents meet separately from the children, but at the same time/location. Children must be entering 3rd-5th grade this Fall to attend the child portion; parents of any age child can attend parent portion: *

Me

Another caregiver

My child

What symptoms or challenges are you hoping to address? Select all that apply to the youth during the past 3 months.

Anxiety or excessive worry

Panic / panic attacks / fears

Depressed mood

Isolation

Extreme or rapidly changing emotions

Anger

Aggression

Oppositional-defiance

Thoughts of suicide (if your child is at imminent risk, please use crisis resources or dial 911)

Non-suicidal self-harm

School refusal

Friendship / relationship problems

Family relationship problems

Academic stress and/or underperformance

Perfectionism

Inattention / distractibility

Hyperactivity / impulsivity

Eating disorder

Trauma or significant stressor

Substance abuse

Obsessive thoughts

Repetitive behaviors

Poor social skills

Developmental delays that impact current functioning

Autism or autistic-like behaviors

Is your child currently in individual therapy? *

No

Yes - with a Bridge to Bridge provider

Yes - with a provider from outside Bridge to Bridge

Has your child been treated in any of the following settings (check all that apply)? *

Medication management with a psychiatrist

Previous psychotherapy

Intensive Outpatient Programs (IOP)

Partial Hospitalization Programs (PHP)

Psychiatric hospitalization

Residential Treatment

None of the above

Is the patient seeking treatment insured by Medicare? *

Yes

No