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Behaviour & Emotional Regulation Screening Form
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Name
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Email
*
Moblie Number
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Age
*
Gender
---Select---
Male
Female
Other
Any Prior Diagnosis (if any):
behavioural Prior Any
Main behavioural concerns you are facing:
---Select---
Hyperactivity
Aggression / hitting
Difficulty following instructions
Tantrums / emotional outbursts
Social interaction difficulties
Other
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