CERTS -Residential Treatment Centers from the CERTS Group

Questionnaire

The following questionnaire has been prepared as a courtesy for families wanting to tell us more about their individual situation. Completing this questionnaire accurately and honestly will help an admissions representative assess whether or not a CERTS program would be beneficial in your situation. If you would prefer to speak directly with an admissions representative, please call 801-755-8802.

All fields with are required fields.

Which CERTS treatment center appears to best fit your daughter?

Parent/Guardian Name:

Address:

City, State, Zip:

Telephone:

Email:

Primary Insurance Provider:

Please answer the following questions as completely as possible. This will help us to better assess your daughter's needs.

Student's First Name:

Student's Age:

Student's Birthdate: mm/dd/yyyy

Relationship to Child:

Parent	Friend of Family
Relative	Other
If Other, please describe:

Please Describe The Problems You Are Having:
(Please limit to 500 characters)

Previous Treatment or Placement:
(Please limit to 500 characters)

Has the student been diagnosed by a mental health professional?
       Yes   No
       If yes, what is the diagnosis? (Please limit to 500 characters)

Is the student currently on any medication? Yes No
If yes, what medications? (Please limit to 500 characters)

Comments/Suggestions:
(Please limit to 500 characters)

CERTS Residential Treatment Centers | PO Box 575780 Murray, UT 84157-5780 | Telephone: 801-755-8802