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Today s Date Teen Name Grade School Screened by Gender DOB Age Source of referral Parent 1 Will Participate Siblings Street City CA Zipcode Home Phone Fax Work Phone Email Cell phone Dx Rx Insurance Inclusion Criteria Teen is 7th 12th Grade Social Problems Teen/Parent fluent in English Parent willing to participate Teen willing to participate Major mental illness Physical Disability Medical Conditions Behavioral Problems Check all that apply Classroom Physically hurts parents Homework Parents...
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