Licensed Therapy Registration- Fall 2025
EEMV Participant Registration for Licensed Therapy- Fall Semester (September 2nd- November 24th) 
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Parent or Caretaker Name (if applicable) 
Participant Name *
Participant Date of Birth *
MM
/
DD
/
YYYY
Participant Primary Diagnosis *
Participant Secondary Diagnosis (if applicable) 
Phone Number *
Email *
Participant Height *
Participant Weight *
Have you participated with our program before?  *
**If you have not participated at EE before, please complete this form and then contact Dayna at dayna@eemv.org or 6363-390-2141 to get our Participant Registration Packet
If new, how did you hear about us? 
Please select the times/days you are available- Select AT LEAST 3 that are possibilities for you *
Required
Any scheduling notes? ( ie. I am only available after 5, etc) 
Client Goals (short term and long term) *
Best way to contact me: 
Clear selection
I'd like to request a financial assistance application (EEMV does not bill insurance- all clients are expected to pay a co-pay of $42 per week)  *
If you are a returning client, have there been any changes to your contact information or medical information since your last full paperwork? This includes changes to height/weight, diagnosis, contact information, etc. 
Clear selection
I have read the form and attest that all the information provided is accurate *
Submit
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