Assessment Questionnaire
The purpose of this questionnaire is to provide information so an assessment can be initiated. All information will be kept strictly confidential and only used to assist Plus Center in placing the person in the best learning environment. 
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Person's Name: *
Date of birth: *
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DD
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Legal Guardians: *
Street Address: *
City/State/Zip Code: *
Home phone number:
Cell phone number:
Email address:
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