Student Information
Student *
Student
Today's Date
Today's Date
Date of Birth
Date of Birth
Student's telephone number if over 18:
Student's telephone number if over 18:
Name of person financially responsible for account:
Name of person financially responsible for account:
Name of person who referred you to us:
Name of person who referred you to us:
Have you ever worked with a consultant before?
If so, who?
If so, who?
Parent Information #1
Student's Parent/Guardian
Student's Parent/Guardian
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell/Alt
Cell/Alt
Parent Information #2
Student's Parent/Guardian
Student's Parent/Guardian
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell/Alt
Cell/Alt
Family Information
Family Member #1
Family Member #1
Family Member #2
Family Member #2
Background Information
Has your child ever been placed in a treatment facility outside of the home?
Is your child on any medication?
Has your child had any involvement with the legal system?
Has your child had any head injuries, hospitalizations or significant medical concerns?
School Information
School Address
School Address
Telephone
Telephone
Please describe any successes or challenges during the student's school history as well as any notable events, friends, themes - both social and academic. Please specify the grades in which the events occurred. Also, please indicate whether the student was in a Private School or Public School setting at the time of the events.
Has your child ever participated in any psycho-educational testing?
If so, approximate date of testing
If so, approximate date of testing