Behavioral Checklist

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805. (Checklist following the Child/Adolescent Intake Form in pdf) Download

Please provide observations of your child's behavior by sharing if the behavior is:

PEERS












SIBLING RELATIONS




















RESTLESS
















TEMPER
















SCHOOL PROBLEMS
























LYING












STEALING












FIRE SETTING








Please list any other information about your child that you feel is important for us to
know about:

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