Please let us know which of the following symptoms you’ve noticed your child has experienced.

 Feeling sad, grumpy Mood swings Loss or gain of weight Feeling tired or having little energy Feeling worthless or guilty Lack of energy or becoming withdrawn Thinks about death or suicide a lot NONE

Has your child been treated with depression before?
 Yes No

Is your child currently receiving treatment for depression?
 Yes No

Does your child have a history of any of the following?

 Seizure Disorder Stroke Head Injury Brain Tumor Cancer NONE

What is the Child's Gender?
 Male Female

How old is your child?
---7891011

Parent's Name (First and Last):

Child's Name (First and Last):

Phone:

Email Address:

Is the child a resident of Washington State?
---YesNo

Zip Code:

What is the best time to contact you?

How did you hear about us?
 TV Radio Referral Flyer/Brochure Internet Search Web Advertisement Facebook Previous Patient Parent Map Seattle’s Child School PTA

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