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TEST Consultation Event Log

Event Survey

Welcome! Thank you for taking the time to log an event.

1. Survey Date (mm/dd/yyyy): *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Please write in your full name:

3. Study ID number: *This question is required. This question requires a valid number format.

4. Event Date (mm/dd/yyyy): *This question is required. This question requires a valid date format of MM/DD/YYYY.

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If there are multiple events (consultation, treatment, and/or supervision) for this youth on the same date, please indicate the order of the event you are currently entering.

Was it recorded? *This question is required.

What type of consent? *This question is required.

What was the outcome? *This question is required.

Please enter an 'other' value for this selection.

What were the outcomes?

Space Cell	Provided	Refused	Other	N/A
Consent for Self	Consent for Self : Provided	Consent for Self : Refused	Consent for Self : Other	Consent for Self : N/A
Consent for Youth	Consent for Youth : Provided	Consent for Youth : Refused	Consent for Youth : Other	Consent for Youth : N/A

Why was consent refused?

Please enter an 'other' value for this selection.

What was the reason for dropout/withdrawal?

Please enter an 'other' value for this selection.

What was the reason for missed treatment?

Please enter an 'other' value for this selection.