Adult Intake and Screening Name(Required) First Last Email(Required) Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Cell PhoneWork PhoneReferred By(Required)Reason for Request(Required)Annual Household Income(Required)Number of Household Members(Required)Highest Grade Completed(Required)Have you ever been diagnosed with a learning disability?(Required) Yes No Is there a history of learning disabilities in your family?(Required) Yes No I Don’t Know Are you currently taking any medications?(Required) Yes No If yes, please list medications here(Required)Have you had a recent psychological assessment within the last two years?(Required) Yes No If yes, when and where(Required)Have you had a recent educational assessment within the last two years?(Required) Yes No If yes, when and where(Required)Do you have any prior convictions?(Required) Yes No CAPTCHA 11647
