Intake Process Profile How did you hear about us? Select one option Search Engine Social Media TV Radio Friend or Family Word of Mouth Legal Name Preferred Name Date of Birth (MM/DD/YYYY) Address Home Life I am an only child. I have one sibling. I have two siblings. I have three or more siblings. Contact Phone Email Education What grade are you currently in? What school do you currently attend? How do you get to school every day? What is your favorite subject? What is your least favorite subject? Which subjects do you excel in understanding? Which subjects do you struggle to understand? Do you receive help with your homework? If so, for which subjects? What do you like the most about your school? What do you dislike the most about your school? Are you a part of any extracurricular activities? Know Thy Self What are some of your favorite foods? Do you have a favorite color? Do you have a favorite book? Who is your best friend? What are your some of your interests?Check all that apply. Athletics Studies Music Art Video Games Mechanics Technology Other Please specify in the box below. What are some of the fears you would like to overcome? What are your short-term goals in life? What are your long-term goals in life? Is there anything else you would like to share about yourself? Submit Δ
FOUR:NINE