Client Information First Name: Last Name: Date of Birth (mm/dd/yyyy): Age: Grade Placement: School Name: School District: School City: School State:

Parent Information First Name: Last Name: Address: Home Phone: Work Phone: Cell Phone: Email Address: Referred By:

Not Interested
Already Accepted
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Concerns

Anxiety Disorder

Asperger's Syndrome

Attention Deficit Disorder (ADD)

Attention Deficit Hyperactivity Disorder (ADHD)

Autism

Communication Disorders

Dyslexia

Gifted and Talented

Health Impairments

Depressive Disorders

Learning Disabilities

Obsessive Compulsive Disorder

Tourette Syndrome

Traumatic Brain Injury

Other Special Learning Needs

Other (Specify below in Goals Box)

Goals

Please describe the academic and non-academic goals you would like to pursue for your child at this school:

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.