Jennifer T. Jefferis, M. Ed., LMHC, NCC
The Academy
400 E. Evergreen Blvd. Ste 302
Vancouver, WA 98660
Phone: 360-696-1137

Please circle concerns:
Depression Explosive behavior Housing conditions Suspicion of others
Work dissatisfaction Feeling alone Eating Disorder Withdrawing from family/friends
Voices or visions Fear of losing control Anxiety/nervousness Loss of loved one
Hyperactive Difficulty with others Bored Financial problem
Marital problems Forgetfulness Insomnia or excessive sleep Worthless feelings
Suicidal thoughts Learning difficulties Crime Victim Angry
Unemployment Family problems Resentful speech/thought
Guilt feelings School difficulties Confusion Child abuse