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* 1. How confident do you feel about your ability to access (connect to and use) Telehealth services for a child or youth with special health care needs?

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* 2. I have the following concerns about Telehealth (check all that apply).

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* 3. I have the devices I need to connect to Telehealth services (check all that apply).

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* 4. Using Telehealth

  Yes No I need help to learn this N/A
I can connect to broadband where I live
I know how to use the devices I have to get Telehealth services
I know how to ask for a Telehealth visit with my child's doctors
I know how to ask for interpreter services for Telehealth visits
I understand the benefits of Telehealth visits
I understand the risks of Telehealth visits

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* 5. Where do you live?

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* 6. In what language do you feel most comfortable expressing yourself? (Optional)

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* 7. (Optional) How do you identify your race and ethnicity? (Check all that apply.)

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