Parent/Guardian Name *

Email *

Phone *

Student Name *

Student Gender *

Male (AMAB)
Female (AFAB)
No elements found. Consider changing the search query.
List is empty.

Student Preferred Pronouns

Student Age *

Current Grade *

Select grade

5th
6th
7th
8th
9th
10th
11th
12th
Post-Secondary
No elements found. Consider changing the search query.
List is empty.

Program of Interest *

Brehm Preparatory School (Grades 6-12)

OPTIONS Transitions to Independence Program (Post-Secondary)

Enrollment Timeline (Select All that Apply) *

Summer

Fall

Spring

Immediate Placement

Reason for Inquiry *

Scope of Neurodiversity (Select All that Apply)

ADHD

Dysgraphia

Depression

Dyslexia

Dyscalculia

Tourette

ASD-1

ASD-2

PDD(NOS)

ODD

NVLD

Anxiety

Auditory Processing

Social Skills Deficit

Executive Functioning Deficit

Other

Other

Meeting Preference *

Video Meeting - Google Meet

Phone Call

By providing my phone number, I agree to receive text messages and emails from Brehm Preparatory School.

Captcha