Student Information Form
Please fill out our new information form so we can learn more about your student! Any contact information entered will be saved and used for billing or business contact.
Email address *
Student Full Name *
Your answer
Parent(s) Full Name *
Your answer
Student's DOB *
Your answer
Student's Gender *
School Setting *
Approximate grade level of material, inclusive versus self-contained, etc.
Your answer
Address *
This will be used as the billing address.
Your answer
Cell phone number *
Your answer
Home phone number
Your answer
How did you find us?
Your answer
Services you are interested in? *
Required
Student's Diagnosis *
Your answer
Previous and Current Therapy *
A student's previous therapies can influence how they respond to specific techniques.
Your answer
Student's current communication skills *
Ability to verbalize, gestures, assistive technology, how do they express themselves, etc.
Your answer
Student's behavior when frustrated or tired. *
We serve all students, regardless of behavior. Knowing what behaviors to expect, however, helps us to better prepare for the lesson.
Your answer
Student's strengths and abilities *
Your answer
Student's repetitive or stimulatory behaviors *
What does the student do to calm or entertain themselves. Examples: singing, spinning, humming, rocking, etc.
Your answer
Agreement for Services *
Unspoken Thoughts, LLC and their employees are not responsible for the actions of my child. I agree to pay Unspoken Thoughts, LLC for the scheduled time spent directly with my child and any other incurred expenses pertaining to my child's services. I agree to attend and observe my child's instruction, unless other arrangements are made. I agree to educate myself about RPM through resources available online and the recommended literature.
Required
Video/Media Release *
Unspoken Thoughts, LLC and their employees are allowed to record or take pictures during their sessions with my child for educational purposes including, but not limited to, training, social media, and our website. Personal videotaping of sessions is allowed for any sessions, but cannot be shared publicly without permission. Any videos or material shared with the family are for personal use only and permission must be acquired before sharing.
Required
A copy of your responses will be emailed to the address you provided.
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