Your Name:    
Telephone:     
Address:         

City:                   
State:                                                         Zip:   
Country:          

Therapist's Name:    
Telephone:              
Address:                   

City:                   
State:                                                           Zip:   
Country:        

Child’s age at start of therapy:        Diagnosed with RAD?    YES NO

Length of therapy

Please number the therapists skills 1-5 (one being the least and five the most)

1. 1 2 3 4 5 Is this child’s primary caregiver expected to actively participate as a vital part of the therapy sessions?
   
2. 1 2 3 4 5 Has your child’s attachment and behavior improved as a result of the work with this therapist?
   
3. 1 2 3 4 5 Does this therapist physically hold the child or have the parents physically hold the child in order to help the child release their rage in a safe environment?
   
4. 1 2 3 4 5 Does this therapist schedule more than 50 minutes for an appointment when needed so the session does not end before the child can complete their rage cycle?
   
5. 1 2 3 4 5 Does this therapist believe the parent’s word over the emotionally disturbed child’s word?
   
6. 1 2 3 4 5 Does this therapist share effective parenting techniques that worked for you?
   
7. 1 2 3 4 5 Is this therapist willing to work with the whole team? i.e. The parents, respite provider, the school, psychiatrist, caseworker, etc.
   
8. 1 2 3 4 5 Is the effectiveness of therapy based on the child’s behavior at home rather than their behavior during therapy?
   
9. 1 2 3 4 5 Does this therapist recognize when the therapeutic needs of the child have changed, such as the need for different therapy, residential inpatient, respite, etc.?
   
10. 1 2 3 4 5 Does this therapist work to build the attachment between the parents and the child before any other bonds?
    
11. 1 2 3 4 5 Does this therapist encourage the parents to take good care of themselves, such as taking regular "breaks", sending the child to their room, using a specially trained babysitter (respite) regularly?
    
12. 1 2 3 4 5 Has this therapist had training in Attachment Therapy from a trained professional?
    
13. 1 2 3 4 5 Does this therapist have hands-on experience doing Attachment Therapy, rather than insight/talk based therapies?
    
14. 1 2 3 4 5 Does this therapist believe in and support the parents; not using hurtful implications, such as "the child isn't’t loved enough" or blaming parents for the child’s misbehavior?
    
15. 1 2 3 4 5 Is this therapist in control during sessions, confronting difficult issues promptly, rather than being controlled by the child’s pathology?
    
16. 1 2 3 4 5 Does this therapist support parents by putting directions in writing, when needed, i.e. for legal purposes?
    
17. 1 2 3 4 5 Does this therapist explore the child’s need for chiropractic, nutritional, exercise, Brain Gym, Sensory Integration, etc.?
    
18. 1 2 3 4 5 Does this therapist do an accurate assessment, such as taking an accurate history and using the RADQ, or CHAFCA?
    
19. 1 2 3 4 5 Does this therapist take into account parents’ concerns about medication?
    
20. 1 2 3 4 5 Would you recommend this therapist to other parents with an emotionally disturbed child?

Additional Comments:

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