1.

* 1. Today's Date:

Date:
/
/

* 2. Child's Date of Birth

Date:
/
/

* 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?

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