Step 1 of 2 50% Scholar Name:(Required) First Last Please Select a School:(Required) Booker T. Washington Middle School Paul Laurence Dunbar High School Renissance High School Intake/Authorization Date(Required) MM slash DD slash YYYY Caregiver Information(Required) First Last Caregiver's relationship to studentBiological/adoptive motherBiological/adoptive fatherFoster motherFoster fatherGrandmotherGrandfatherUncleAuntStepmotherStepfatherOtherDepression and Depressive DisordersYesNo (e.g., Major Depressive Disorder, Disruptive Mood Dysregulation Disorder) Bipolar and Related DisordersYesNo Anxiety Disorders and PhobiasYesNo(e.g., Social Anxiety, Separation Anxiety, Selective Mutism, Panic Disorder) Obsessive-Compulsive and Related DisordersYesNo(e.g., OCD, Hoarding Disorder, Trichotillomania, Body Dysmorphic Disorder) Trauma and Stressor-Related DisordersYesNo(e.g., PTSD, Acute Stress Disorder, Adjustment Disorder, Reactive Attachment Disorder) DevelopmentalYesNo(Autism Spectrum, Intellectual Disability, Global Developmental Delay) Attention-Deficit/Hyperactivity DisorderYesNo Conduct/Disruptive/Impulse Control Disorders (ODD, CD)YesNo Substance-Related and Addictive DisordersYesNo Schizophrenia Spectrum and Other Psychotic DisordersYesNo Feeding and Eating DisordersYesNo If any other, please describe. Youth Pediatric Symptom ChecklistThese questions are for youth between 4 and 16 years. Feels sad, unhappy?(Required)NeverSometimesOftenFeels hopeless?(Required)NeverSometimesOftenIs down on him or her self..(Required)NeverSometimesOftenWorries a lot…(Required)NeverSometimesOftenSeems to have less fun…(Required)NeverSometimesOftenFidgety, unable to sit still…(Required)NeverSometimesOftenDaydreams too much…(Required)NeverSometimesOftenDistracted easily…(Required)NeverSometimesOftenHas trouble concentrating…(Required)NeverSometimesOftenActs as if driven by a motor…(Required)NeverSometimesOftenFights with other children…(Required)NeverSometimesOftenDoes not listen to rules….(Required)NeverSometimesOftenDoes not understand other people’s feelings….(Required)NeverSometimesOftenTease others….(Required)NeverSometimesOftenBlames others for his or her troubles….(Required)NeverSometimesOftenRefuses to share…(Required)NeverSometimesOftenTake things that do not belong to him or her…(Required)NeverSometimesOften