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Information

Client Info

Name

Age

Date of Birth (mm/dd/yyyy)

Grade Placement

School Name

School District

School City

School State

Parent Info

Parent Name(s)

Address

Primary Telephone

Secondary Telephone

Email Address

Adult Responsible

Referred By



Goals

Please list and describe at least three academic and non-academic goals the student would like to pursue this school year


Testing

A copy of any recent testing the student has completed would be helpful in creating the most effective academic program for the student.
A copy of recent testing will be sent to SEPS
SEPS has all current testing
No other testing has been done
Other

Terms

While we take every precaution to ensure your child is safe, SEPS does not accept liability for accidents or mishaps that may occur while your student is in school or under the supervision of SEPS staff. 24-hour notice is required for cancellations. Appointments missed without prior notification will be charged. Advance payments should be made on the first day of each month. Payment plans are available—please call Dr. AvaJane Pickering for more information. Payment for all programs is expected at the time of registration or on the first day of the session. SEPS does not accept insurance or credit cards. SEPS reserves the right to withhold grades until full payment has been made. Any disputes regarding payment will be resolved via mediation or binding arbitration.