This document is a mental health questionnaire for children ages 13-20 in the Maryland Healthy Kids Program. It asks about a variety of mental health issues including attention problems, strange thoughts, hearing voices, problems at school or with friends, feelings of sadness or anger, risky behaviors like substance use or self-harm, stressors in the family, and history of abuse or accidents. Providers are asked to give details for any positive responses and the form can also be used to refer children for further mental health support.