Registration - Adult

Registrant Information
Date of Birth
Address
Please check all that apply.
$
Please enter digits only, no commas.
$
Please enter digits only, no commas.
Third parties include such groups as the Mass. Rehab. Commission, DDS, NH Voc. Rehab, or a school or corporation.
Diagnosis and Treatment
Order
Diagnosing doctor's address
years old
Please check all that apply.
Order
Permission to speak?
Name
Role/Area of Specialization
Phone
Email
Goals Worked On
When was your last primary care appointment?
Goals and Interests
Order
Examples: time management, organization work, asking for help from teachers, working in groups, interviewing skills, planning for college, making social connections, etc.
Order
History
Conviction will not disqualify any registrant from participating in this program.
Please enter any other important information about yourself here.
Statement of Truth
I certify that information contained in this registration form is true and complete. I understand that false information may be grounds for not accepting me to participate or for immediate termination of participation in this program. I authorize the verification of any or all information listed above.
Please type your name to indicate that you agree to the statement of truth above.
If the person completing this registration form is not the client, please type that person's name to indicate that they agree to the statement of truth above.