The Bodin Group
Why Call Bodin?
Who We Are
About us
Our Team
What We Do
Consulting
Testing
Mentoring
College Consulting
Schools & Programs
Media
Success Stories
Reading List
News Letter
Contact
Forms
Why Call Bodin?
/
Who We Are
/
About us
Our Team
What We Do
/
Consulting
Testing
Mentoring
College Consulting
Schools & Programs
/
Media
/
Success Stories
Reading List
News Letter
Contact
/
Forms
/
Educational and Therapeutic Consultants
DUP - Regx
Why Call Bodin?
/
Who We Are
/
About us
Our Team
What We Do
/
Consulting
Testing
Mentoring
College Consulting
Schools & Programs
/
Media
/
Success Stories
Reading List
News Letter
Contact
/
Forms
/
Student Information
Student
*
First Name
Last Name
Prefers to be called
Today's Date
MM
DD
YYYY
Date of Birth
MM
DD
YYYY
Gender
*
Grade
1
2
3
4
5
6
7
8
9
10
11
12
Student's telephone number if over 18:
(###)
###
####
Student's e-mail if over 18:
Name of person financially responsible for account:
First Name
Last Name
Name of person who referred you to us:
First Name
Last Name
Have you ever worked with a consultant before?
Yes
No
If so, who?
First Name
Last Name
Parent Information #1
Student's Parent/Guardian
First Name
Last Name
Relation to student:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Cell/Alt
(###)
###
####
Email
Employer
Parent Information #2
Student's Parent/Guardian
First Name
Last Name
Relation to student:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Cell/Alt
(###)
###
####
Email
Employer
Family Information
Family Member #1
First Name
Last Name
Relationship
Occupation/Education
Age
Family Member #2
First Name
Last Name
Relationship
Occupation/Education
Age
Background Information
Please describe current living arrangements. Include blended family members with whom the child lives and any custody and/or visitation arrangements.
Is this your biological child?
What are the educational, behavioral, emotional and/or psychiatric concerns that prompted this appointment?
What is the history of these concerns?
Has your child ever been placed in a treatment facility outside of the home?
Yes
No
If YES, please indicate the name of the facility, when the placement occurred, and for how long your child was placed. Additionally, we welcome your thoughts and/or feelings about your and your child's experience at the facility.
If applicable, please describe your child's history of substance abuse. List all substances you are aware of that s/he used, when started, and frequency of use.
If applicable, please describe any family history of mental health or substance abuse issues.
Is your child on any medication?
Yes
No
If YES, which ones, for how long and the dosage? Who is the prescribing physician?
Has your child had any involvement with the legal system?
Yes
No
If YES, please describe.
Has your child had any head injuries, hospitalizations or significant medical concerns?
Yes
No
If YES, please describe.
What are your child's strengths, talents and passions?
School Information
Current School
Current Grade
1
2
3
4
5
6
7
8
9
10
11
12
School Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Contact
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.
Grade | School Name | Social orAcademic Comments | Public or Private #1
Grade | School Name | Social orAcademic Comments | Public or Private #2
Grade | School Name | Social orAcademic Comments | Public or Private #3
Grade | School Name | Social orAcademic Comments | Public or Private #4
Does your child have an active IEP? If yes, provide dates. Does he/she have an active 504 Plan? (IEP=Individualized Educational Plan written by school administration and school district personnel)
Describe any special education or modified academic programs your child has been in.
Describe any suspensions or expulsions from school. Give reasons:
Does your child like school?
Please describe your child's hobbies/sports/extracurricular activities:
Has your child ever participated in any psycho-educational testing?
yes
no
If so, approximate date of testing
MM
DD
YYYY
With whom?
Phone Contact
Though we will be discussing your child in detail when we meet, is there something specific you want us to know that we have not asked in this form?
Thank you for filling out our registration form.
