Child and Youth Mental Health General Screening Questionnaire – Caregiver Submission

This information will assist us in providing the best possible care for you and your family. Your answers will be kept strictly confidential as part of your child’s, teen’s or your clinical record.

If information through the course of this questionnaire suggests there may be harm to yourself or to others, including abuse or neglect, I am required by law to report my concerns to the appropriate authorities.

Please know that answering these questions is completely voluntary and will not affect the services you may receive from Island Community Services. However, we invite you to be as open as you can be to help us determine how best to support you and your child.

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