Intake Form

Student/Client First & Last Name*
Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Gender*
- Female
- Male
- Prefer not to say
Grade for Current School Year*
- Preschool
- K
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- College
Mailing Address (street, city/town, zip)
Student Phone Number
Student Email Address
Tell us about your child's talents, interests, academic and/or personal strengths:
What are you child's areas of academic difficulty and/or personal challenges?
District & school your student/client attends
Does he/she receive supports/services through an Individualized Education Plan (IEP) or 504-Accommodation Plan? If so, please specify which plan.
- Individualized Education Plan
- 504-Accommodation Plan
- Not currently receiving any supports/services through either plan
If your child is receiving supports/services through an IEP or 504, what is the primary disability area? If not applicable, please write "N/A"
How did you hear about MES?
What is the service and/or program you are interested in at MES?

Emergency Contact
Person available in case parent cannot be reached in an emergency
Emergency Contact Name*
Relationship to Student*
Emergency Contact Phone Number*

Other:
Special requests and permission:
Do you have any special requests or questions regarding participation in any MES Services?
Do you give permission for your child to be photographed for publicity, advertising or web content?*
- No, I do not give permission for my child to be photographed.
- Yes, you have my permission to photograph my child while attending a MES session
Do you have any additional information you would like to share?

Validation
Please "sign" your name below. In doing so, the Parent/Guardian is attesting that the above information is accurate to the best of their knowledge.*
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Parent or Guardian Information