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Adult Testing Intake form
Intake Form for consideration of Adult Testing Services from SpEdConnecticut, Inc.
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* Indicates required question
Name:
*
Your answer
Address:
*
Please include full mailing address.
Your answer
Phone number - Home:
*
Your answer
Phone number - Cell:
*
Your answer
What is the best time to reach you?
*
Time
:
AM
PM
Email:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Are you currently employed?
*
Yes
No
Required
If YES - Employer Name and Address:
Your answer
If YES - Position and # of Years:
Your answer
Marital Status:
*
Married
Seperated
Divorced
Single
Required
Number of Dependents living with you?
*
Your answer
Are you living as a Dependent?
*
Yes
No
Required
If Yes, with whom?
Your answer
Highest Level of Education:
*
High School Graduate
GED
Vocational School
College
Required
If College, please indicate your major and date of graduation?
Your answer
Have you ever been diagnosed with a learning disability or ADHD?
*
Yes
No
Required
If Yes, please indicate by whom and when the diagnosis was made:
Your answer
What diagnosis were you given?
Your answer
Is this the issue you are contacting us about now?
Yes
No
Clear selection
Who referred you?
*
Your answer
Primary Reason for your Interest in SpEdConnecticut
*
Please describe briefly the problem you are having and what your desired outcome would be.
Your answer
Annual Household Income
*
$0 - $19,999
$20,000 - $39,999
$40,000 - $54,999
$55,000 - $69,999
$70,000 - $84,999
$85,000 +
By completing this form, neither you nor SpEdConnecticut are obligated to perform any services until a contract for services has been entered into and signed by both parties.
*
Yes, I agree with the above terms and conditions
Required
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