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Scripts
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Parents
Parent New Assessment Form
Parent Follow-up Form
ADHD in GIRLS and WOMEN
Adult ADHD
MCHAT SCREEN for Autistic Spectrum Disorder
Video interview consent
Teachers
Teachers new patients
Teacher Follow-up Form
Video consent
Video Consent and Release Form
Name of Child referred to in the Video interview
First
Last
Parent or legal guardian of the above-named minor child.
First
Last
The below-signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.
Email
*
Consent is given to Dr. John Flett for the purpose of education
This consent includes, but is not limited to: ( select where applicable)
*
Deselect All
(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice
(b) Permission to use my name.
(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.
This consent is given in perpetuity and does not require prior approval by me.
Date
*
DD slash MM slash YYYY
Signature of Parent or Legal Guardian:
*
Should you need clarification regarding the consent or any other concern, please do not hesitate to contact me before signing the consent.
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