Please complete the following. Read each sentence carefully. For each statement, check the bubble in the column that best corresponds to how often you have felt that way during the past two weeks.

For statements 5 and 7, if you are on a diet, answer as if you were not.

Did your child have any difficulty in any of the following areas? (For example, were any of these areas especially hard for the child or was the child slower to do them than you would expect?)

Please answer yes or no. If yes, please explain.

Please answer each question as best as you can.

1. Has there ever been a period of time when you were not your usual self and...

To be filled out by the mother of the child (or father, only if the mother is unavailable).

Listed below are items concerning children's behavior and the problems they sometimes have. Read each item carefully and decide how much you think your child was bothered by these problems when he/she was between 6 and 10 years old. Rate the amount of the problem by putting a check in the column that describes your child at that time.

By typing my name and checking the box “I agree” at the bottom of this form, I understand and agree that I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (ii) I agree to the remaining terms of this Consent, including the terms of the Privacy Notice and Financial Policy described on https://sisonpsychiatry.com/forms/

If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.

• I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different locations or site than I am.

• I understand that the telemedicine visit will be done through a two-way video link-up. The healthcare provider will be able to see my image on the screen and hear my voice. I will be able to hear and see the healthcare provider.

• I understand that the laws that protect privacy and the confidentiality of medical information including (HIPPA) also apply to telemedicine.

• I understand that I will be responsible for any copayments or coinsurances that apply to my telemedicine visit.

• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care of treatment.

• I understand that by signing this form that I am consenting to receive psychiatric care via telemedicine.

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