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.