Registration - Adult

Diagnosis and Treatment

Do you have any of these diagnoses?		Order
	Diagnosis Diagnosis Approximate Age at Diagnosis Approximate Age at Diagnosis Diagnosis by self/medical professional Diagnosis by self/medical professional Name of Other diagnosis (if applicable) Name of Other diagnosis (if applicable) Do you have any of these diagnoses?	Weight for row 1

Other Service Provider Information		Order
	Permission to speak? Permission to speak? Name Name Role/Area of Specialization Role/Area of Specialization Phone Phone Email Email Goals Worked On Goals Worked On Other Service Provider Information	Weight for row 1

Goals and Interests

Name 1 or 2 things you would like assistance with *		Order
	Name 1 or 2 things you would like assistance with *	Weight for row 1
	Name 1 or 2 things you would like assistance with (value 2)	Weight for row 2

Examples: time management, organization work, asking for help from teachers, working in groups, interviewing skills, planning for college, making social connections, etc.

What special interests do you have?	Order
	What special interests do you have?	Weight for row 1
	What special interests do you have? (value 2)	Weight for row 2

History

Conviction will not disqualify any registrant from participating in this program.

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.