For us to provide your child (11-17 years old) with the best possible care, we would like to know how things are going...

Home Risk Assessment

Does he/she eat meals with the family?
Does he/she have a family member/adult to turn to for help?
Is he/she permitted and able to make independent decisions?

Education Assessment

How does he/she perform in school?
How does he/she pay attention & obey instructions?
How does he/she do with homework?

Eating Assessment

He/She eats regular meals including adequate fruits and vegetables.
He/She drinks non-sweetened liquids.
He/She gets the recommended amount of calcium.
He/She has concerns about body or appearance.

Activities Assessment

He/She has friends.
He/She gets at least 1 hour of physical activity per day.
He/She spends less than 2 hours/day in front of a screen (besides homework).
He/She has interests/participates in community activities/volunteers.

Drug Assessment (substance use/abuse)

He/She uses tobacco/alcohol/drugs.

Safety Assessment

His/Her home is free of violence.
He/She uses safety belts/safety equipment.
He/She has peer relationships free of violence.

Sex Assessment

He/She has had oral sex.
He/She has had sexual intercourse (vaginal, anal).

Suicidality/Mental Health Assessment

He/She has healthy ways to cope with stress.
He/She displays self-confidence.
He/She has problems with sleep.
He/She gets depressed, anxious, or irritable/has mood swings.
He/She has thought about hurting self or considered suicide.

Drugs (Substance Use/Abuse)

He/She uses tobacco products.
He/She drinks alcohol.
He/She uses drugs (street and/or prescription).
He/She uses steroids.
He/She has driven or ridden in a car driven by someone who was "high" or had been using alcohol or drugs.
He/She uses alcohol or drugs to relax, feel better about self, or fit in.
He/She uses drugs when he/she is alone.
He/She has forgotten what he/she did while using alcohol or drugs.
He/She has been told by friends and family to cut down on drinking or using.
He/She has gotten into trouble while using alcohol and/or drugs.

Suicide / Mental Health

He/She has experienced depression.
He/She has experienced anxiety.
He/She has had a suicidal ideation(s).
He/She has had a suicidal attempt(s).
He/She has a history of pyschologic counseling.
He/She has an other mental health diagnosis.


He/She has experience with either bullying others or being bullied.
He/She has interest and/or experience with guns.

Electronic Assessment

Approximately how many hours/day does he/she spend watching TV or videos?
Approximately how many hours/day does he/she spend playing video games?
Approximately how many hours/day does he/she spend on social media (ex. Instagram)?

Please fill out all required fields and click the "Submit" button at the end of the questionnaire. 

Following completion, an email will be sent to you with results and how to follow up.

© 2018 Refined Transitions

Please call during our hours of contact to schedule an appointment. If you call after hours, we will return your phone call during our hours of contact.

Monday - Friday

8:00am - 4:00pm


4445 Eastgate Mall Rd #200

San Diego, CA 92121