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Incredible Years Intake Form
Fremont Connections
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Caregiver name(s)
*
Your answer
Gender of caregiver signing up
Female
Male
Other gender identity
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Race
Black or African American
Asian
Multi-Racial
White or Caucasian
Middle Eastern
Declined/Unknown
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Phone number
*
Your answer
Address
*
Your answer
Email address
*
Your answer
Relationship to child(ren):
Your answer
Can both parents attend the sessions?
*
Yes
No
What are your children's names and their ages?
*
Your answer
Does your child receive any support services? (IEP, therapy, counseling, etc.)
*
Yes
No
Option 3
OhioRISE Involvement?
Yes
No
Unknown
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How did you hear about us?
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Your answer
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