Adult Intake and Screening Adult Intake and Screening Name * Email * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Date of Birth * Home Phone * Cell Phone Work Phone Referred By Reason for Request Household Income * Number of Household Members Highest Grade Completed Have you ever been diagnosed with a learning disability? Yes No Is there a history of learning disabilities in your family? Yes No Are you currently taking any medication? Yes No If so, please list here Have you had a recent psychological/educational assessment within the last two years? Yes No If so, when If so, where Do you have any prior convictions? Yes No If you are human, leave this field blank. Submit
