Chakaura by Michele

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ChakauraTM Power Your Life!

To Transform, Create and Heal

with Michèle St. Amour

Chakaura Parent Form For Youth Program

Chakaura Parent Form For Youth Program

Responses are private and confidential. Chakaura adheres to high codes of ethics and privacy and only under law or if a person was life threatened would we share private information to the proper authority.

Name(Required)
Address(Required)
Is this your first experience with Chakaura services?(Required)
How did you hear about our services?(Required)
Do you understand and agree to the idea working with your teen/youth requires your participation and support:(Required)
What other avenues have you looked to for support:(Required)
How committed are you to supporting your youth?(Required)
What is your level of communication with your youth?(Required)
How open are you to holistic (outside of the medical system) forms of support for yourself and your youth?(Required)
How much experience have you had with holistic (outside of the medical system) forms of support for yourself and your youth?(Required)

Over the last two months, how often has your youth been bothered by any of the following symptoms?

Little interest or pleasure in doing things:(Required)
Feeling down, depressed, irritable, or hopeless:(Required)
Trouble falling or staying asleep, or sleeping too much:(Required)
Feeling tired or having little energy:(Required)
Poor appetite, weight loss, or overeating:(Required)
Feeling bad about himself/herself, feeling like a failure, or that she/he has let herself/himself or the family down:(Required)
Moving or speaking so slowly that other people could have noticed? Or the opposite: being so fidgety or restless that he has been moving around a lot more than usual:(Required)
Thoughts that she/he would be better off dead, or of hurting himself in some way(Required)
How long have you been concerned about the health of your youth?(Required)
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