Adult Intake and Screening Adult Intake and Screening Name * Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Birth * Home Phone * Cell Phone Work Phone Referred By * Reason for Request Household Income * Number of Household Members Highest Grade Completed Have you ever been diagnosed with a learning disability? Yes No Is there a history of learning disabilities in your family? Yes No Are you currently taking any medication? Yes No If so, please list here Have you had a recent psychological/educational assessment within the last two years? Yes No If so, when If so, where Do you have any prior convictions? Yes No If you are human, leave this field blank. Submit
