Lilley Consulting
Registration Form
Student Information
First Name*
Middle Name
Last Name*
Suffix
Nick Name
Date of Birth
Gender
Male
Female
Transgender
Gender Expansive
Gender Fluid
Gender Neutral
Unknown
Sex
Male
Female
Intersex
Unknown
Height
2' 0"
2' 1"
2' 2"
2' 3"
2' 4"
2' 5"
2' 6"
2' 7"
2' 8"
2' 9"
2' 10"
2' 11"
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3' 5"
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3' 10"
3' 11"
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4' 5"
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4' 8"
4' 9"
4' 10"
4' 11"
5' 0"
5' 1"
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5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
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6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7' 0"
7' 1"
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7' 3"
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7' 5"
7' 6"
7' 7"
7' 8"
7' 9"
7' 10"
7' 11"
8' 0"
8' 1"
8' 2"
8' 3"
Weight
Student Cell
Home Phone
Email
Add Parent or Guardian
Family Information and Student History
* What concerns have prompted this appointment? Please include behavioral, academic, and emotional concerns.
* What is the history of these concerns? How long have they existed? Have any other concerns led to this point?
Please list everyone who lives in the home. If shared custody, list members of both homes.
Add A Person who lives with the Student
Please describe student's current living arrangements. Include all family members whom the student lives with and the current custody/visitation arrangements.
School
Current School
Grade
if summer please mark grade student will enter in the fall
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Freshman
Sophomore
Junior
Senior
Post Graduate
Current School Address
City
State
Zip Code
Country
Current School Phone Number
Name and Phone Number of person to contact at the school
Describe any special education programs the student has participated in.
No
Yes
Does the student have an Individualized Education Plan (IEP)?
No
Yes
Does the student have a 504 plan?
Describe any suspensions or expulsions from school, including reasons.
Student's interests/hobbies/sports/extra curricular activities:
Health Concerns
No
Yes
Has the student ever been placed in a residential program or hospital?
Please describe any concerns with substance abuse. Please include details regarding which substances and time frame of use.
Please describe any family history of mental health or substance abuse concerns.
If the student is on any medications, please list the medication name, reason for medication, and dose amount.
If the student has had any involvement with the legal system, please describe.
Thank you, just two more questions...
No
Yes
Have you ever worked with a therapeutic or educational consultant?
How did you hear about Lilley Consulting?
Send Registration
Parent or Guardian Information
Prefix
First Name
Middle Name
Last Name
Suffix
Nick Name
Kinship Type
Adoptive
Bio
Self
Step
Kinship
Aunt
Brother
Daughter
Father
God Father
God Mother
Grandfather
Grandmother
Great Grandmother
Guardian
Husband
Mother
Partner
Sister
Son
Step Father
Step Mother
Uncle
Wife
Student Lives Here?
Yes
No
Parent's Cell
Home Phone
Parent's Email
Street
City
State
Zip
Employer
Occupation
Work Email
Work Phone
Work Ext
Work Fax
Remove this Parent/Guardian
Name
Age
Resides Where?
Relationship To Student
Employment\Education
Remove Person
SRPdb Nov 21, 2024