Intake – Disability Consulting & Training
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Today's Date
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A: Student Identification
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Age
0 of 3 max characters
Preferred Name
Gender
Home Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Email
I prefer to get calls
at home
on my cell
B. Family
Parent/Guardian 1
Phone
Parent/Guardian 2
Phone
Sibling name
Age
Sibling name
Age
Sibling name
Age
Sibling name
Age
C. Referral Source
How did you locate Disability Consulting and Training?
Referred by someone
Advertisement
Presentation
Website
Other
Name of referral source
D. Educational History
Name of school currently attending
Address of school currently attending
Department/Case Manager/POC at school
E. Medical History
Medical Diagnosis
Does student see a mental health provider?
What is the reason for seeing a therapist?
If so, please list name/contact information
F. Student Information
Please describe the strengths of your child
Please describe the needs of your child
What do you hope to gain from our partnership?
Is there anything else that you would like to share with me?
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