Parent/Guardian: *

First Name

Last Name

Relationship to Child: *

Parent

Guardian

Other

Child’s *

First Name

Last Name

Child’s Date of Birth *

MM

DD

YYYY

Date of Form Submission *

MM

DD

YYYY

Therapist’s *

First Name

Last Name

Therapy Modality Used (if known) *

CBT

DBT

Play Therapy

EMDR

Talk Therapy

Other

How were sessions conducted? *

In-person

Telehealth

Mixed

Have all 5 approved sessions been completed? *

Yes

No

How frequently were the sessions scheduled? *

Weekly

Biweekly

Other

Did the therapist maintain regular communication with you (parent/guardian)? *

Yes

No

Occasionally

Mood Stability – Before Therapy (1 = No Concern, 5 = Severe) *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

Mood Stability – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

Anxiety Levels – Before Therapy (1 = No Concern, 5 = Severe) *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

Anxiety Levels – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

Depression / Sadness – Before Therapy (1 = No Concern, 5 = Severe)ls *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

Depression / Sadness – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

School Participation – Before Therapy (1 = No Concern, 5 = Severe)ls *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

School Participation – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

Social Interaction – Before Therapy (1 = No Concern, 5 = Severe)ls *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

Social Interaction – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

Anger / Irritability – Before Therapy (1 = No Concern, 5 = Severe)ls *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

Anger / Irritability – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

Sleep Patterns – Before Therapy (1 = No Concern, 5 = Severe)ls *

1 – No Concern

2 – Mild

3 – Moderate

4 – Serious

5 – Severe

Sleep Patterns – After 5 Sessions (1 = Much Worse, 5 = Much Improved) *

1 – Much Worse

2 – Slightly Worse

3 – No Change

4 – Slightly Improved

5 – Much Improved

Has the child begun using any new coping skills or tools since therapy began? *

Yes

No

Not Sure

Are there still major concerns you feel have not been addressed? *

Yes

No

Do you feel that therapy is helping your child? *

Yes – Significant Improvement

Yes – Some Improvement

Not Sure Yet

No – No Real Change

No – It’s Been Detrimental

Do you believe continued therapy is necessary at this time? *

Yes

No

Unsure

If we are able to extend support, would you like to continue with the same therapist? *

Yes

No

Open to Discussing Options

Would you be willing to share a short testimonial or quote about your experience (anonymized if used publicly)? *

Yes

No

Has anything changed financially or logistically since your original application (insurance, income, schedule, etc.)? *

Yes

No