Monday Family Group Course Intake Form

Name*

First Last

Email Address*

Phone Number*

Secondary Phone Number

The participants in these sessions will be:*

If the number of participants who would like to attend is different than the number you paid for in your registration, please email admin@efsuccess.info.

Name of Primary Participant (if other than above)

First Last

Preferred Pronouns

Other Session Participants (if applicable):

Please provide the full name of each participant, their preferred pronouns, and their relationship to the primary participant. Remember, if the primary client is a student, a least one parent or adult support figure MUST attend the sessions as well.

General Intake Information

Primary Concerns

Please identify any of the following that apply to the primary client(s):

ADD/ADHD, Dyslexia, Learning Differences, Gifted and Talented, Processing Disorders, Premature Birth, Adopted, Mental Health Diagnosis

Referral Source*

Please let us know how you heard of us.

Additional Questions for Students and Families

Please fill out this section if the primary participant is a student.

Student Age(s)

Current School(s)

Current Grade Level(s)

Cancellation Policy*

Yes, I understand the cancellation policy

I understand that a 100% refund is available up until two weeks before the first day of class. A 50% refund is available from two weeks prior to the first day of class through the second class. No refunds are available after the second week of class. I understand that if for any reason, the group environment isn’t suitable for myself or my student, I may apply the cost of the group course towards private sessions at a pro-rated amount.

Monday Group Course

General Intake Information

Additional Questions for Students and Families