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What We Do
Who We Are
Admissions
- Selection Process
- Tuition
Graduates
Testimonials
Contact Us

Parent Anxiety Rating Form

Parent Anxiety Form

Name
First Last
Email
Smoking / Vaping
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Refusing medication
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Not sleeping
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Cell phone usage
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Not talking to parents
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Sick / Doesn't feel well
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Doesn't have a job
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Ran out of money
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Drinking Alcohol
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Not exercising
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Bad hygiene
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Isolating / No friends
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack
Not participating in program
- 1 - Not concerned
- 2 - Mildly concerned
- 3 - Moderately concerned
- 4 - Highly concerned
- 5 - Mildly worried
- 6 - Moderately worried
- 7 - Highly worried
- 8 - Mild Panic
- 9 - Moderately Panic
- 10 - Panic Attack

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