Adult Testing Intake form
Intake Form for consideration of Adult Testing Services from SpEdConnecticut, Inc.
Name: *
Your answer
Address: *
Please include full mailing address.
Your answer
Phone number - Home: *
Your answer
Phone number - Cell: *
Your answer
What is the best time to reach you? *
Time
:
Email: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Are you currently employed? *
Required
If YES - Employer Name and Address:
Your answer
If YES - Position and # of Years:
Your answer
Marital Status: *
Required
Number of Dependents living with you? *
Your answer
Are you living as a Dependent? *
Required
If Yes, with whom?
Your answer
Highest Level of Education: *
Required
If College, please indicate your major and date of graduation?
Your answer
Have you ever been diagnosed with a learning disability or ADHD? *
Required
If Yes, please indicate by whom and when the diagnosis was made:
Your answer
What diagnosis were you given?
Your answer
Is this the issue you are contacting us about now?
Who referred you? *
Your answer
Primary Reason for your Interest in SpEdConnecticut *
Please describe briefly the problem you are having and what your desired outcome would be.
Your answer
Annual Household Income *
By completing this form, neither you nor SpEdConnecticut are obligated to perform any services until a contract for services has been entered into and signed by both parties. *
Required
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