Please fill out the following information about yourself and the child.
Your Name
Phone Number
Email Address
Child Name
Child Age
Please select the signs you noticed. A text field will appear when you check a box.
Persistent sadness or withdrawal
Severe irritability or exaggerated reactions
Sudden social withdrawal
Unusual aggression
Sudden drop in academic performance
Very high distractibility
Major changes in sleep
Major changes in appetite
Frequent stomachache or headache
Constant feeling of fatigue
Extreme separation anxiety
Fear of being near a specific person
Talking about self-harm
Sexual behavior inappropriate for age
