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New York, NY
Northern Virginia
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Washington, D.C.
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The Ross Center

Washington, D.C.

5225 Wisconsin Avenue NW, Suite 400
Washington, DC 20015

The Ross Center

Northern Virginia

1595 Spring Hill Road, Suite 520
Vienna, VA 22182

The Ross Center

New York, NY

57 W. 57th St., Suite 912
New York, NY 10019

Optimal Treatment for Anxiety & Mental Health

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Commitment to Inclusivity: The Ross Center is an equal opportunity organization, and does not discriminate on the basis of race, age, ethnicity, ancestry, national origin, disability, color, size, religion, gender, sexual orientation, marital status, or socioeconomic background. We are committed to providing an inclusive and welcoming environment for all patients and members of our staff. To learn why we include pronouns on each provider’s bio, click here. For any questions, or to report any concerns, please contact us at info@rosscenter.com.

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Supportive Parenting for Anxious Childhood Emotions (SPACE) Screening Form

Thank you for your interest in our SPACE-informed parenting group. Our group is designed to work with parents of children whose primary difficulty is anxiety with related avoidance behavior. Please answer the following questions so that we can gain a better understanding of you and your child.

SPACE Form

Parent/Caregiver Names:

Marital Status:

Child’s Name:

Child’s age:

Child’s DOB:

Child's Grade in School (*Please note this group is for children in grades 1-5):

Email:

Phone:

Home Address:

Street Adress City State / Province / Region ZIP / Postal Code

Region:

Participants

Who is seeking to participate in the SPACE group? (Please specify each participant’s relationship to the child.)

Diagnosis

Has your child ever been diagnosed with a mental health disorder? If so, please explain:

Treatment

Is your child involved in any mental health treatment (i.e., parent coaching, individual therapy, medication management, family therapy, etc.?) If yes, please list the name of the treatment provider and type of treatment.

Hospitalization

Has your child ever been referred to or participated in an intensive outpatient treatment, partial hospital program, or inpatient hospitalization? If yes, please explain and include dates of treatment.

School Attendance

Is your child currently attending school (remote or in person?) Has your child ever struggled to attend school consistently?

Anxiety

What are the ways that your child’s anxiety is interfering with family/parent functioning?

Comments

This field is for validation purposes and should be left unchanged.

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Top Ethical Issues in Today’s Medical-Legal Environment. 2 CE Program for Mental Health Providers. 10/28/22

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