Application - Teen

Applicant Information
Date of Birth
Address
$
Enter digits only, no commas
Diagnosis and Treatment
Diagnosing doctor's address
years old
Order
First
Middle
Last
Specialty
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 applicant from participating in this program.
Payment Method
Statement of Truth
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not accepting me to participate or for immediate termination of this program. I authorize verification of any or all information listed above.
Please type your name to indicate that you agree to the statement of truth above.
A parent of the client must type his or her name to indicate agreement of that parent to the statement of truth above.