To be on our list of parent approved attachment therapists, this referal form must be filled out by a parent of a child diagnosed with Reactive Attachment Disorder who has worked with the therapist.

If you prefer you may download and print a copy and mail it in. Therapists, you may print out form and give them to your clients to fill out and return to Nancy Thomas Parenting.

By spending a few minutes to answer these twenty questions you can help other parents be able to access effective help for their child. All identifying information will be kept confidential. Recommended Attachment Therapists will receive a star from each parent’s referral.

Your Information:
Your Name:
Phone:
Address:
City:
State:
Zip Code;
Country:
Your Therapists Information:
Therapists Name:
Phone:
Address:
City:
State:
Zip Code:
Country:
Child's Age At The Start Of Therapy:
Child Diagnosed With RAD?	YES NO
Length Of Therapy:

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

1. Is this child’s primary caregiver expected to actively participate as a vital part of the therapy sessions?	1 2 3 4 5
2. Has your child’s attachment and behavior improved as a result of the work with this therapist?	1 2 3 4 5
3. 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?	1 2 3 4 5
4. 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?	1 2 3 4 5
5. Does this therapist believe the parent’s word over the emotionally disturbed child’s word?	1 2 3 4 5
6. Does this therapist share effective parenting techniques that worked for you?	1 2 3 4 5
7. Is this therapist willing to work with the whole team? i.e. The parents, respite provider, the school, psychiatrist, caseworker, etc.	1 2 3 4 5
8. Is the effectiveness of therapy based on the child’s behavior at home rather than their behavior during therapy?	1 2 3 4 5
9. Does this therapist recognize when the therapeutic needs of the child have changed, such as the need for different therapy, residential inpatient, respite, etc.?	1 2 3 4 5
10. Does this therapist work to build the attachment between the parents and the child before any other bonds?	1 2 3 4 5
11. 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?	1 2 3 4 5
12. Has this therapist had training in Attachment Therapy from a trained professional?	1 2 3 4 5
13. Does this therapist have hands-on experience doing Attachment Therapy, rather than insight/talk based therapies?	1 2 3 4 5
14. 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?	1 2 3 4 5
15. Is this therapist in control during sessions, confronting difficult issues promptly, rather than being controlled by the child’s pathology?	1 2 3 4 5
16. Does this therapist support parents by putting directions in writing, when needed, i.e. for legal purposes?	1 2 3 4 5
17. Does this therapist explore the child’s need for chiropractic, nutritional, exercise, Brain Gym, Sensory Integration, etc.?	1 2 3 4 5
18. Does this therapist do an accurate assessment, such as taking an accurate history and using the RADQ, or CHAFCA?	1 2 3 4 5
19. Does this therapist take into account parents’ concerns about medication?	1 2 3 4 5
20. Would you recommend this therapist to other parents with an emotionally disturbed child?	1 2 3 4 5

Additional Comments:

This test prevents automated submissions Enter the text that appears in above image: