Registration and Payment - Meyer Education & Family Services

Registration and Payment

Please complete each step of the Registration form below and then continue to make a Payment.

Please complete each step of the Registration form below and then continue to make a Payment.

Registration and Payment

Fill out each step to complete registration and continue to payment.

Step 1 of 7

Client Info
Name
First Last
Age
Gender
Phone
Email

Parent Info
Name (Required)*
First Last
Age
Gender
Phone (Required)*
Email (Required)*

Second Parent Info (Optional)
Name
First Last
Age
Gender
Phone
Email

Family History / Concerns
What is occurring that has caused you contact Meyer EFS?
Include The History and behaviors and any previous approaches/strategies you have attempted.
Child’s interest’s and strengths:

School Information
Current school and grade
Does the client have an IEP or 504?
Explain any suspensions or expulsions

Medical History
Is the client taking medication? If so, what type and dosage?
Has the client been hospitalized? If so, explain the circumstances.
Is there a family history of mental illness or substance abuse? If so explain.

Legal History
Does the client have any outstanding legal issues or a history of legal issues.
How did you find out about Meyer EFS?
How did you find out about Meyer EFS? (Required)*
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.