Parent Registration Form

All information is confidential and sent over a secure connection.

Your Name (required):

Your Email (required):

Student's Name:

Date of Birth:

Age:

Contact Telephone Number:

Street Address:

City:

State:

Zip Code:

Country:

Parent 1 Name:

Parent 1 Phone:

Parent 1 Email:

Parent 2 Name:

Parent 2 Phone:

Parent 2 Email:

Step-parent Name:

Step-parent Phone:

Step-parent Email:

Student lives with:

Who has custody?

EDUCATIONAL HISTORY

Current School:

Guidance Counselor/School Social Worker:

Previous schools attended. Please include dates of attendance and type (public, private or home):

List two favorite teachers and their subjects:

List extra-curricular activities, hobbies and interests:

Does your child have learning differences?

Has your child had emotional, social or behavioral concerns?

Is your child receiving special help at school?

Any other school concerns?

What type of school or program do you envisions working best for your child?

MEDICAL HISTORY

Mental health history (psychotherapy, hospitalizations):

List any current medical problems or physical challenges:

List any current medications (including psychiatric):

Pediatrician/Doctor Name:

Pediatrician/Doctor Phone:

Pediatrician/Doctor Address:

Date of Last Physical Exam:

Outcome:

Psychiatrist Name:

Psychiatrist Phone:

Psychiatrist Address:

All information is confidential and sent over a secure connection.