Online Web Form Test Get connected to care for your child Your Name* First Last What is your relationship to the child/teen?* Name of the child/teen for whom you're seeking information* First Last How old is the child/teen?*Please enter a number from 0 to 18.Where do you currently live?* Where does the child/teen currently live?* If your child or teen has insurance, what type of insurance coverage do they have?* Agile Blue Cross Blue Shield Group Health/Health Partners PreferredOne Medica UCare United Health Group Other coverage My child does not have insurance AsessmentMy child acts impulsively or without concern for risk* Not at all Slight Moderate Severe My child’s energy is hard to regulate or manage* Not at all Slight Moderate Severe It’s a challenge for my child to maintain focus* Not at all Slight Moderate Severe My child repeats certain behaviors or activities* Not at all Slight Moderate Severe My child is having difficulty in school (in-person)* Not at all Slight Moderate Severe My child is having difficulty in school (digital/distanced learning)* Not at all Slight Moderate Severe My child’s mood shifts unexpectedly* Not at all Slight Moderate Severe My child has thoughts, fears, or worries that make it hard for them to function* Not at all Slight Moderate Severe My child has eating or body image concerns* Not at all Slight Moderate Severe My child engages in negative self-talk* Not at all Slight Moderate Severe My child has difficulty relating to peers* Not at all Slight Moderate Severe I am concerned that my child may be using tobacco, alcohol, or drugs* Not at all Slight Moderate Severe My child experiences anger, irritability or rage* Not at all Slight Moderate Severe My child is displaying physical aggression (hitting, kicking, throwing things)* Not at all Slight Moderate Severe Has your child witnessed a traumatic event?* No Yes If you answered yes, please briefly describe the event if comfortable:Was there a significant loss in your child’s life, such as a death, transition or divorce?* No Yes If you answered yes, please briefly describe the loss or transition if comfortable:Has a teacher or pediatrician asked your child to complete a behavioral, emotional or developmental assessment?* No Yes, but we have not completed it. Yes, we had my child take an evaluation. If you've completed an evaluation, what was the outcome of the assessment?Contact InformationIf you have any other requests, information or concerns regarding your child, please share them in the box below.Please include any psych testing, types of therapy, or any specific clinician skills/traits/identities that would be most helpful for your child or teen.Would you rather be initially reached by email or phone?*PhoneEmailPlease note: the official referral requires a phone call, but email is a great starting point if it is more comfortable for you, the parent or caretaker.Phone number* Email* May we leave a message for you on this email/number?* Yes No Any communication with Washburn Center is private and protected under HIPPA guidelines and regulationsWhat day is best for Washburn Center to reach out? Select All Monday Tuesday Wednesday Thursday Friday Any communication with Washburn Center is private and protected under HIPPA guidelines and regulationsWhat time is best for Washburn Center to reach out? Select All 8 a.m. to 9 a.m. 9 a.m. to 10 a.m. 10 a.m. to 11 a.m. 11 a.m. to noon Noon to 1 p.m. 1 p.m. to 2 p.m. 2 p.m. to 3 p.m. 3 p.m. to 4 p.m. 4 p.m. to 5 p.m. 5 p.m. to 6 p.m. Any communication with Washburn Center is private and protected under HIPPA guidelines and regulationsHow did you hear about Washburn Center?GoogleSocial MediaFriendSchool CounselorDoctor or TherapistAdvertisementSomewhere elseIs there a program that you think would be a good fit for your child?I would like advice on where my child may get the best care.Case managementCrisis StabilizationDay TreatmentFamily FocusedIntensive In-homeOutpatient individual therapyOutpatient family therapyOutreach programWAARM (Washburn Allina Acute Response Model)CAPTCHA
