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The Listening Program® Client History Child Form

We created our Listening Program® Client History Child Form to help improve your Listening Program experience. Now you no longer need to print out the 12 page form and send it to us. You can simply fill out this form online and submit it. Every time someone uses this form, it saves 12 pages of paper, which helps our environment. If, for whatever reason, you need to use the original pdf format, you can access that form by clicking here.

Once we receive your information, we will contact you to set up an appointment for your free Listening Program® consultation. In the meantime, please feel free to call us at 800-957-5655 or contact us online.

 

Please fill in as much information as possible so we can best assist you.
You may be prompted at required fields.
Today's Date:
 (mm/dd/yyyy)
 / /
Form completed by
(check one):
Mom Dad Guardian
 
Child's (Client's) Name:
(child doing the program)
 Child's Date of Birth:
 (mm/dd/yyyy)
 / /
 
Address:
 		City:
 
State:
 Zip:
 Home Phone:
                
 
Was child adopted
(check one) Yes No 		If yes, child's age at adoption:
Child currently lives with (check one):
Mom Dad Guardian
 
Father's Name:
 Father's Date of Birth:(mm/dd/yyyy)
/ /
 
Address:
 		City:
 
State:
 Zip:
 Country:
                
 
Home Phone:
 Work Phone:
 
Fax:
 Email:
 
Education Completed:
 Occupation:
 
Mother's Name:
 Mother's Date of Birth:(mm/dd/yyyy)
/ /
 
Address:
 		City:
 
State:
 Zip:
 Country:
                
 
Home Phone:
 Work Phone:
 
Fax:
 Email:
 
Education Completed:
 Occupation:
 
Guardian's Name:
 Guardian's Date of Birth:(mm/dd/yyyy)
/ /
 
Address:
 		City:
 
State:
 Zip:
 Country:
                
 
Home Phone:
 Work Phone:
 
Fax:
 Email:
 
Education Completed:
 Occupation:
 

1. Family Information
           Family Member or Live-In Care Giver Age Currently using TLP?
Name: 
Name: 
Name: 
Name: 
Name: 
Name: 
Name: 
Name: 

 

2. How did you become aware of TLP? (check one):
    Professional Group Publication Internet Other

 

Person or Place where you became aware of TLP
Name:  

 
 Please use the continue button below to continue.
 








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This site does not provide medical advice, diagnosis, or treatment and is intended for informational purposes only. No therapeutic relationship is established by the use of this site. Randi Fredricks is a Licensed Marriage Family Therapist MFC 47803. Randi Fredricks is not licensed with the California Medical Board or the Bureau of Naturopathic Medicine.
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