Registration - Advanced Pragmatics

Please answer the following questions about the Client to apply:

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Items marked with an * are required.

Information About the Client:

Client's Full Name*:

Client's Gender:
FemaleMaleOther

Client's Date of Birth*:

Current Grade:
4th5th6th12thHS Graduate

Client's School:

List any specific diagnoses for the Client (Please state "None" if no exist)*:

List any relevant medical conditions for the Client (Please state "None" if none exist)*:

What type of special education program does the client attend? (e.g., Mild-Moderate Special Education/RSP, Moderate-Severe Special Education/SDC, General Education with supports, General Education with one-on-one aide, General Education without an IEP) *:

Information About the Client's Parent/Guardian:

Name of Client's Parent/Guardian*:

Telephone Numbers for Client's Parent/Guardian*:

Email Address for Client's Parent/Guardian*:

As the Parent/Guardian, what are your goals for your son or daughter while they are participating in social groups?:

How did you hear about us?: