Registration - Adult

Registrant Information
Date of Birth
Please check all that apply.
Third parties include such groups as the Mass. Rehab. Commission, DDS, NH Voc. Rehab, or a school or corporation.
Diagnosis and Treatment
Approximate Age at Diagnosis
Diagnosis by self/medical professional
Name of Other diagnosis (if applicable)
Please check all that apply.
Permission to speak?
Role/Area of Specialization
Goals Worked On
Goals and Interests
Examples: time management, organization work, asking for help from teachers, working in groups, interviewing skills, planning for college, making social connections, etc.
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.