To apply for participation in the research,

Please enter your name here:

Please enter your e-mail address:

1. Do you have at least one child between the ages of 5 and 12 years old?

Yes

No

2. Are you a resident of California?

Yes

No

3. Are you a divorced or single parent?

Yes

No

4. Does your child receive special education services at school?

Yes

No

5. Does your child have a psychological or psychiatric diagnosis?

Yes

No

6. Does anyone in the child's immediate family (mother, father, siblings) currently recieve psychological or psychiatric counseling ?

Yes

No

Open-ended Commentary

Please feel free to add whatever comments you'd like to about your child or your family