Page 6C - 17 *MHDiagnosis ____ 0 No 1 Yes – – Social connectedness: ___ ___ 01 No attendance in the past month 04 8 15 times in past month Page 6C - 18 – – – 02 1-3 times in past month 05 16-30 times in past month – – 03 4-7 times in past month 06 Some attendance in past month, frequency unknown – – school attendance: ___ Page 6C - 18 1 Suspended 2 Expelled 3 Suspended and Expelled 4 Not Applicable – – – – Signature: Date: //
*MHDiagnosis ____ 0 – No 1 – Yes Page 6C - 17 Social connectedness: ___ ___ 01 – No attendance in the past month 04 – 8 – 15 times in past month 02 – 1-3 times in past month 05 – 16-30 times in past month 03 – 4-7 times in past month 06 – Some attendance in past month, frequency unknown Page 6C - 18 school attendance: ___ 1 – Suspended 2 – Expelled 3 – Suspended and Expelled 4 – Not Applicable Page 6C - 18 Signature: Date: //
Form%20OUTC%20Detox.docx