The Bodin Group Registration Form
Contact Email
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Confirmation Email
Email address is required. Upon completion of the form, you will receive an email with a link to the form if you need to make any edits or updates to it. Please note: The form is only accessible later if you click submit on the 6th page of this form.
Student Information
Student's Name
First Name
Last Name
Prefers to be called
Date of Birth
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Month
/
Day
Year
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Date of Birth
Gender
Grade
N/A
1
2
3
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5
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10
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12
Student's Telephone Number (if over 18)
Student's E-mail (if over 18)
Name of person financially responsible for this account
First Name
Last Name
Name of person who referred you to us
First Name
Last Name
Have you ever worked with a consultant before?
Yes
No
If so, who?
First Name
Last Name
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Student Information
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Parent/Guardian Information #1
Student's Parent/Guardian
First Name
Last Name
Relation to Student
Address
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone
Work Phone
Mobile Phone
E-mail
Employer
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Parent/Guardian Information #1
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Parent/Guardian Information #2
Student's Parent/Guardian
First Name
Last Name
Relation to Student
Address
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone
Work Phone
Mobile Phone
E-mail
Employer
Page 3 of 6
Parent/Guardian Information #2
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Family Information
Family Member #1
First Name
Last Name
Relationship
Occupation/Education
Age
Family Member #2
First Name
Last Name
Relationship
Occupation/Education
Age
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Family Information
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Background Information
Current Living Arrangements
Please describe current living arrangements. Include blended family members with whom the child lives and any custody and/or visitation arrangements.
Is this your biological child?
Yes
No
Concerns
What are the educational, behavioral, emotional and/or psychiatric concerns that prompted this appointment?
History
What is the history of these concerns?
Treatment
Yes
No
Has your child ever been placed in a treatment facility outside of the home?
If Yes
If YES, please indicate the name of the facility, when the placement occurred, and for how long your child was placed. Additionally, we welcome your thoughts and/or feelings about your and your child's experience at the facility.
Substance Abuse
If applicable, please describe your child's history of substance abuse. List all substances you are aware of that s/he used, when started, and frequency of use.
Family History
If applicable, please describe any family history of mental health or substance abuse issues.
Medication
Yes
No
Is your child on any medication?
If YES, which ones, for how long and the dosage? Who is the prescribing physician?
Medication
How Long
Dosage
Prescribing Physician
#1
#2
#3
#4
#6
#7
#8
Legal
Yes
No
Has your child had any involvement with the legal system?
If Yes, Please Describe
Medical Concerns
Yes
No
Has your child had any head injuries, hospitalizations or significant medical concerns?
If Yes, Please Describe
What are your child's strengths, talents and passions?
Page 5 of 6
Background Information
Are you choosing to submit now to save existing data?
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Yes
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School Information
Current School
Grade
1
2
3
4
5
6
7
8
9
10
11
12
N/A
School Address
Street Address
Street Address Line 2
City
State
Zip Code
Contact
First Name
Last Name
Telephone
School History
Please describe any successes or challenges during the student's school history as well as any notable events, friends, themes - both social and academic. Please specify the grades in which the events occurred. Also, please indicate whether the student was in a Private School or Public School setting at the time of the events.
#1
Grade | School Name | Social or Academic Comments | Public or Private
#2
Grade | School Name | Social or Academic Comments | Public or Private
#3
Grade | School Name | Social or Academic Comments | Public or Private
#4
Grade | School Name | Social or Academic Comments | Public or Private
Does your child have an active IEP?
If yes, provide dates. Does he/she have an active 504 Plan? (IEP=Individualized Educational Plan written by school administration and school district personnel)
Modified Academic Programs
Describe any special education or modified academic programs your child has been in.
Suspensions or Expulsions
Describe any suspensions or expulsions from school. Give reasons:
Does your child like school?
Extracurricular Activities
Please describe your child's hobbies/sports/extracurricular activities:
Psycho-Educational Testing
Yes
No
Has your child ever participated in any psycho-educational testing?
If so, approximate date of testing
-
Month
-
Day
Year
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With whom?
Phone Contact
Specific Issue/Concern
Though we will be discussing your child in detail when we meet, is there something specific you want us to know that we have not asked in this form?
Please Verify Form Completion. Click on Completed Circle below before hitting submit.
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Please click Submit below to finish The Bodin Group Online Registration Form. If you do not click submit than your entered data will not be saved.
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