Application Brehm Application Email Parent/Guardian First Name Parent/Guardian Last Name Phone When is the best time to reach you? Mailing Address * Country How did you hear about Brehm? Educational Consultant Internet Search Professional referral Family/Friend Referral Conference or Event Reference Social Media Current Student Other Prospective Student’s Name What has led to your inquiry today? Do you have a current Neuropsychological evaluation (within 3 years)? Yes No Testing is scheduled or in progress. We need help getting the necessary testing. Other: Student’s Preferred Pronouns Please list all official diagnoses for the individual. * What are the student’s academic strengths? Student’s Birthdate What are the main academic concerns? What are the student’s social /personal strengths? Students Age What are the main social/personal concerns? What strengths does your student demonstrate regarding daily living activities? Radio Buttons 6th 7th 8th 9th 10th 11th 12th What concerns do you have about your student’s daily living activities? Is your student on any medications? If so, please list all of them including, OTC medications. Current Educational Programming or Placement Does your student have any medical concerns, including allergies and special diets? What are your student’s hobbies/interests? Previous Educational Programming or Placements Please describe your student’s relationship with technology, including phone and other devices. Please explain any history of physical aggression. Does your student have an IEP? YesNoOther Please explain any history of drug abuse. Does your student have a 504? YesNoOther What goals do you have for your student? What goals does your student have for the future? What is your enrollment timeline? ImmediateFallSpringSummer OnlySummer & FallOther: Captcha Payment If you are human, leave this field blank. Submit
