Student Inquiry

Your Child's Full Name *

Child's Current Age *

Child's Date of Birth *

Are you looking to apply for the current school year? *

What school is your child currently attending? *

What is your child's current grade? *

Please list any medical diagnosis and the approximate date of diagnosis for your child: *

Currently, is your child in any therapy and/or counseling? *

How often (if any) does your child exhibit aggression towards others? *

Does your child take any medications? (Prescribed, supplements, vitamins, holistic) *

If yes to the above question, please list name and reason for medication.

Tell us a little about your child. What do they like to do outside of school? What are their strengths/challenges? *

What do you desire in a school environment for your child? *

Is there anything else that you would like to share about your child and/or family?

Please provide your contact information below:

Name *

Phone *

Email Address *