Assessment Form – Lifestyle Interventions

Questionnaire

Name:

Relationship to teen or young adult:

Email:

Phone:

Parental Guardian #1

Parental Guardian #2

Address:

How did you hear about us?

Has your teen or young adult received any diagnoses or treatment for mental health issues in the past?

Is your teen or young adult currently taking any medications for mental health issues?

Has your teen or young adult everbeen hospitalized for mental health reasons?

Is your teen or young adult currently working with a mental health professional?

Have you noticed any signs of drug or alcohol use in your teen or young adult?

Has your teen or young adult used drugs or alcohol in the past?

Is your teen or young adult currently using drugs or alcohol?

Has your teen or young adult ever struggled with addiction or dependency?

Is there any history of self-harm or suicidal ideation in your teen or young adult?

Are there any safety concerns that we should be aware of?

What is your teen’s or young adult's current grade level?

What are your teen or young adult's current grades like?

Does your teen or young adult have any learning disabilities or accommodations?

Is your teen or young adult presenting any behavioral issues?

What are some of your teen or young adult's interests and hobbies?

Does your teen or young adult have a consistent support network that they are engaged in?

Who is in your teen or young adult's current support system (family, friends, mental health professionals)?

What are your teen or young adult's short-term goals (1-3 months)?

What are your teen or young adult's long-term goals (6 months to a year)?

Is your teen or young adult motivated to participate in the mentoring program?

What do you hope your teen or young adult will gain from the mentoring experience?

What are some of your teen or young adult's strengths?

What are some of your teen or young adult's challenges or areas for growth?

Psychological:

Social: