CERTS -Residential Treatment Centers from the CERTS Group

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Your Child


	I have wanted to write a thank you note for a long time, but honestly, I have been afraid to do so before now. Of course, I don't know what tomorrow holds. But today, one year later, we will rejoice in her first birthday of sobriety. On September 18th, in the Courage to Change it says, "If someone had told me a year ago that I would be where I am today, I wouldn't have believed it possible." That's exactly how we feel today. As she and I attend Alanon and NA in the same building on Sundays, I read that to her as we were walking out to the car last week. She kissed my forehead and said, "I love you too, Mom." - C.J. Illinois

Please answer the following assessment as honestly and accurately as you can. Your results will be processed and will give you an indication of what is recommended for your child. All information submitted is confidential. The results will be displayed upon pressing the submit button.

This assessment is for my:
Son     Daughter

Has your child had recurring problems due to:

Any traumatic events/changes such as abuse, divorce, or death, in his life?
        Yes             No

Inability to manage anger?
        Yes             No

Within the last six months, has your child:

Disregarded family rules and parental guidance?
        Yes             No

Had any changes in behavior and/or mood?
        Yes             No

Exhibited depressive symptoms, such as weight loss/gain or excessive sleep?
        Yes             No

Had problems getting along with others?
        Yes             No

Do you suspect that your child has used drugs or alcohol?
        Yes             No

Had problems in school such as poor grades or challenging authority?
        Yes             No

Has your child been able to manipulate people and situations in order to escape consequences?
        Yes             No

Been destructive to property?
        Yes             No

Intentionally frightened others?
        Yes             No

Made threatening statements in writing?
        Yes             No

Implied that they may have a plan for violent or suicidal behavior?
        Yes             No

Implied that they have identified a target for violence?
        Yes             No

CERTS Residential Treatment Centers | PO Box 575780 Murray, UT 84157-5780 | Telephone: 801-755-8802