SEEDS Therapy Center
Program Inquiry Form

Please fill out the following form to schedule a 30-minute screening to determine eligibility for STC services. Please note: this form is not a guarantee of service.

Potential Client Information

First Name of Potential Client

Last Name of Potential Client

Client Age:

Date of Birth

Client Gender:

Address

Phone Number:

Current Diagnosis (Please list all)

Current School/Work/Day Program:

Living Environment:

At home

Group Home

Residential Facility

Foster Placement

Other

Is the individual Conserved? *

No

Yes

Reason for Inquiry:

Funding Source

Are you a client of SDRC? *

Yes

No

Are you enrolled in the Self-Determination Program or plan to in the next 6 months?

SDRC Coordinator Name:

SDRC Coordinator Phone Number:

SDRC Coordinator Email

Parent/ Guardian/ Conservator Information

Parent/ Guardian/ Conservator Name

Relationship to client:

Home Phone:

Cell Phone:

Email:

Preferred Method of Contact:

Cell Phone

Home Phone

Email

Best Time to Contact:

AM

PM

Any Additional Information:

Thanks for submitting! We will be in contact with you soon!

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SEEDS Therapy Center Program Inquiry Form

Potential Client Information

Funding Source

Parent/ Guardian/ Conservator Information

SEEDS Therapy Center
Program Inquiry Form