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1.

1. Today's Date:

Date:
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2. Child's Date of Birth

Date:
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3. Your child's age

* 4. Please completed all sections

5. What symptom does your child have that is most concerning to you?

6. Please circle the number that is closest to how you feel

  Strongly agree Agree Neutral Disagree Strongly disagree
I learned information that I will be able to use
I learned something new
I will make changes because of what I learned today
The speaker was interesting
I understand what the next steps are
I would recommend the webinar to a friend

7. Other comments about the program:

8. If you have additional questions, can we contact you to answer them?

T