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Seeing My Time Group Course Intake Form
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Seeing My Time Group Course Intake Form
Please fill this out before the first class!
I am signed up for:
*
In-person class, Saturdays
Online class, Tuesdays
Name
*
First
Last
Email Address
*
Phone Number
*
Secondary Phone Number
The participants in these sessions will be:
*
1 Adult
Family of 2 (1 Adult, 1 Family Member)
Family of 3 (1 Adult, 2 Family Members)
Family of 4 (1 Adult, 3 Family Members)
Family of 5 (1 Adult, 4 Family Members)
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.
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