Please complete to the best of your ability

No personally-identifiable information is shared with any other entity or person. 

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* 1. Your Name

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* 2. Your age

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* 3. Mailing Address

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* 4. Email address (for Zoom invitation)

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* 5. Best phone number

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* 6. Name & Age of most challenging child

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* 7. That child's sex

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* 8. Your relationship to that child

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* 9. Your marital status

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* 10. Names, Ages, Sex, and Relationship of all who live with that child

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* 11. Is your child in regular contact with anyone for emotional or behavioral problems? Please describe if so.

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* 12. Age/s of All Children (living with you or not)

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* 13. What type of household does the child live in?

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* 14. Your highest level of education

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* 15. If you have a partner, Their highest level of education

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* 16. Are you employed or self-employed?

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* 17. If you have a partner, are they employed or self-employed?

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* 18. Does your family receive government benefits?

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* 19. If so, what kind?

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* 20. In the last 6 months, have you or you partner sought or received professional support from a Psychologist, Psychiatrist, Counselor, Social Worker, or other Mental Health Provider?

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* 21. Check any issues your child has experienced:

0 of 21 answered
 

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