SCG Intake Form: Schools

Student's Full Name *

First

Last

Preferred Name

Student's Preferred Pronouns *

Date of Birth

Student's Email *

Student's Cell Phone *

Current School *

Current Grade *

Schools Previously Attended

Please include name of school(s) and grades attended.

Does the student have an Indvidual Education Plan (IEP) or a 504 Plan at School?

Has the student ever completed educational or psychological testing?

If applicable, please share more about your child's learning differences and/or any current or past diagnoses.