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Registration - Teen

Registrant Information

Your name*

Your name
First* Middle Last*

Date of Birth

Address

Country*

Street address*

City*

State*

Zip code*

Email 1*

Email 2

Phone 1*

Phone 2

Gender

Male

Female

Non-binary

Other

Ethnicity

White (non-Hispanic)

Black (non-Hispanic)

Hispanic

Native American or Alaskan Native

Asian or Pacific Islander

Other

What is your approximate family annual income? $

Enter digits only, no commas

Which school are your currently attending?

What is your current grade in school?

Are you on an IEP?

Yes

What are your living arrangements?

I live with my parent(s)

Other

Are you working?

Do you drive?

Yes

How did you learn about this program?

Diagnosis and Treatment

What is your present diagnosis?

Male

Female

Non-binary

Other

What is the name of the doctor who made the diagnosis?

Re-order	First	Last	Credentials (e.g. MD)	Weight
	First	Last	Credentials (e.g. MD)	Item weight

Diagnosing doctor's address

Country

Street address*

City*

State*

Zip code*

Diagnosing doctor's phone

Age at diagnosis years old

May we speak with your doctor?

Yes

Are you working with other professionals such as a therapist, coach, case manager, speech therapist, etc?

Yes

If YES, please indicate the setting

Individual

Group

If YES, please indicate names and specialties

Re-order	First	Middle	Last	Specialty	Weight
	First	Middle	Last	Specialty	Item weight

Do you have a primary care physician?

Yes

When was your last primary care appointment?

Goals and Interests

Name 1 or 2 things you would like assistance with*

Name 1 or 2 things you would like assistance with
Name 1 or 2 things you would like assistance with
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?

What special interests do you have?
What special interests do you have?
What special interests do you have?

History

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

Have you ever had any legal difficulties?

Yes

If YES, please explain

Payment Method

Payment

Self-pay

Cost sharing

School District

Other

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.

Client Signature*

Please type your name to indicate that you agree to the statement of truth above.

Parent Signature*

A parent of the client must type their name to indicate agreement of that parent to the statement of truth above.