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Level III Treatment
First NameLast Name (Initial)
Agency
Pre-Test DatePost-Test Date
Gender of Adult Completing This FormMaleFemale
Gender of "Target" ChildMaleFemale
What is the Consumer's primary race? (Race of the Consumer's most recent biological ancestors?)
What language does the Consumer use most often?
What was the parenting status of the Caretaker provided for the Consumer?
What is the relationship between the Consumer and the previous Caretaker?
How long did the Consumer reside with the Caretaker (0 if child not living with you)
Where did the Consumer reside prior to receiving out of home placement