Registration - Adult

For which program are you registering?
Registrant Information
Your name
Address
Gender
Ethnicity
Are you currently working/in school?
Please check all that apply.
What are your living arrangements?
Do you drive?
Do you have access to a car?
Will you or a family member be paying for LifeMAP, or do you anticipate that it will be funded by a third party?
Third parties include such groups as the Mass. Rehab. Commission, DDS, NH Voc. Rehab, or a school or corporation.
Diagnosis and Treatment
Re-order Diagnosis Approximate Diagnosis by self/medical professional Name of Other diagnosis (if applicable) Weight
Please indicate any benefits/services you are receiving
Please check all that apply.
Are you working with other professionals such as a therapist, coach, case manager, speech therapist, etc?
Re-order Permission to speak? Name Role/Area of Specialization Phone Goals Worked On Weight
Goals and Interests
Name 1 or 2 things you would like assistance with
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?
History
Conviction will not disqualify any registrant from participating in this program.
Have you attended a LifeMAP Informational Session?
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.
Are you currently under guardianship of any kind?
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.