thinkSMART Application

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* 1. Parent's name (first and last):

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* 2. Email address:

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* 3. Daytime phone number:

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* 4. How did you hear about thinkSMART?

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* 5. thinkSMART is typically held Mondays from 5 - 6:30 pm. Do you or your teen have any potential time conflicts with this?

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* 6. Teen's name

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* 7. Date of birth

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* 8. Age

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* 9. Grade

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* 10. Biological Sex

Male

Female

Other

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* 11. Diagnoses (if applicable)

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* 12. Age of diagnoses (if applicable)

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* 13. Is your teen able to be in a mainstream classroom and able to sit for 90 minutes?

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* 14. Primary parent(s)/guardian(s) to attend SMART with youth (Mom, Dad, etc.)

Mom

Dad

Other (please specify)

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* 15. What skills would you like to see your teen gain from thinkSMART?

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* 16. What types of difficulties is your teen having that prompted your interest in the program?