Three Springs

Adolescent Treatment Programs

Questionnaire

Because every family is unique it helps us to learn more about your particular situation. Out of respect to you and your child, Three Springs will keep all the information you provide completely confidential. Please only provide the information you feel comfortable sharing.

If you simply want to ask a question, you can also e-mail us at info@threesprings.com or call 888-758-4356.

Your Name: *

Is your child Male or Female?:

Male

Female

Child's Name:

Relationship to child: ParentRelativeFriend of FamilyOther

If other:

Age of the child: *

Describe the child's behaviors:

Are you working with a professional?:

No

Yes

If so, who?:

Would you like us to call you?:

Do not call

Please call

Telephone:

Email: *

Address:

City:

State: *

Zip: