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* 1. What is your child’s gender?

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* 2. What grade is your child in?

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* 3. What is your child’s birthday?

Date

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* 4. At age was your child diagnosed with ADHD?

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* 5. What was the initial cause(s) for concern?

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* 6. What does your child’s treatment plan include?

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* 7. Who referred your child to a mental health professional?

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