PARTICIPANT APPLICATION Culinary Weightloss Show (Working Title)
|
|
|
- Agatha Hubbard
- 8 years ago
- Views:
Transcription
1 PARTICIPANT APPLICATION Culinary Weightloss Show (Working Title) Use dark colored ink. Please write only on the printed side of the paper, but feel free to attach additional sheets if necessary. ELIGIBILITY REQUIREMENTS MUST BE A LEGAL U.S. RESIDENT. MUST BE 18 YEARS OF AGE OR OLDER. Full Legal Name & Nickname (if applicable): Current Address & Current city (no PO Box): Hometown City city you were raised: Home number & work number: Cell number (circle best number to reach you) (personal&/or work) WEBSITE: (personal &/or business) TWITTER: SKYPE NAME: FACEBOOK :(or how we can find you on FB) Legal Age (dob): Gender: M F (circle one) Marital Status (Circle all that apply): Single Married Divorced Remarried Widowed Engaged Separated Live with significant other Common-law Marriage Spouse s/partners Occupation: If spouse/ Parter is in food business does he/she struggle with weight?
2 Children (List names and ages) I am a legal resident of the United States: Yes No ANY OTHER FAMILY MEMBERS IN THE FOOD BUSINESS (Children, parents, siblings, etc ) Describe their jobs/occupation Your highest Level of Education: School(s) you attended from highschool on (include technical schools, trade schools, culinary schools, trade certificates, grad schools, etc ) Height: Weight: HOW MUCH WEIGHT DO YOU NEED TO LOSE? WHY IS NOW THE TIME IN YOUR LIFE YOU WANT TO MAKE THIS TREMENDOUS CHANGE? WHEN WAS YOUR AHA MOMENT I AM OVERWEIGHT! DESCRIBE Was their an embarrassing moment attached to the AHA moment?
3 WHY DO YOU FEEL THIS OPPORTUNITY ON THE CULINARY WEIGHTLOSS TV SHOW WILL BE A GREAT PLATFORM FOR YOU TO LOSE THE WEIGHT? (Are you desperate? Do you want to set an example for others? There is no wrong answer) WHAT IS AT STAKE IF YOU DON T TAKE CONTROL OF YOUR HEALTH IMMEDIATELY? Why do you deserve this opportunity? WHAT IS YOUR CURRENT & OR PAST OCCUPATION(S) IN THE FOOD BUSINESS: DESCRIBE IN DETAIL FROM CHILDHOOD to present? HOW LONG HAVE YOU BEEN IN THE FOOD BUSINESS? (include details- even if you took a hiatus from the food business or are currently out of the food business tell us the details OR perhaps you were raised around food but didn t work in the business until you were an adult-tell us the details) Perhaps you are an Executive chef? Perhaps you moved up in the ranks? Perhaps you were a pizza delivery person and now a restaurant owner? Perhaps you grew up on a ranch raising cattle? Perhaps you are a truck driver for a seafood/produce company? DOES YOUR DAY REVOLVE AROUND FOOD? DESCRIBE
4 DO YOU EAT ON THE GO OR EAT ALL DAY LONG? LIST EVERYTHING YOU EAT ON A TYPICAL DAY Describe proudest accomplishments in the Food Business if any personally or professionally (Ex. you won a cooking/baking contest as a child, you have a food blog, recipe site, opened a deli/restaurant, have a chain of take-outs, you were on a cooking show, you cooked for a well-known chef, you own a farm to table restaurant etc..) PLEASE DESCRIBE YOUR JOB RESPONSIBILITY IN DETAIL AND THE HOURS YOU WORK AND HOW FAR YOUR JOB IS FROM YOUR HOME WHEN WAS THE LAST TIME YOU WERE AT YOUR IDEAL WEIGHT? Did you lose weight alone or with help? Trainers? Diets? Surgery? Bands? Medication? Therapy? How long did the weightloss take?
5 LIST ALL THE DIETS YOU CAN REMEMBER TRYING: WHEN DID YOU START NEGLECTING YOUR HEALTH? What have you been focusing on? Everyone else? Was it gradual or sudden? Describe? Why do you think you struggle with weight? Was it emotional? Was it due to sickness in the family? Did life just get in the way? Is eating an emotional tradition in the family? Did you have good food role models?details Do you have any other family members who struggle with weight? Who? Relation to you? Do they have diabetes? High blood pressure? Describe Does your weight affect ALL aspects of your life? Describe? (even the simplest things) walking outside? Playing with children? Walking up steps? Carrying things for your job? Working long hours? Sleeping? Spending time with family?
6 Does your weight affect your goals and dreams? Has weight held you back? Does the public treat you differently because you are overweight? If you were not in the food business do you think you would still be struggling with weight? Describe? Describe a typical work day for you and a typical day off for you? (Include your responsibilities, work, family, kids, FOOD intake & living situation). Include how it might be different if you were at your ideal weight WHAT IS SOMETHING ABOUT YOU THAT MOST PEOPLE DON T KNOW or we might find interesting? Hobbies? Interests? Accolades? Won beauty pageants? You were a star athlete? You collect something? You have travelled around the world? You were class president? You went to Lawschool? You speak five languages? You went to the Olympics? You have a passion for reading? WHAT ARE THE THINGS YOU DON T GET TO EXPERIENCE BECAUSE YOUR WEIGHT HOLDS YOU BACK? Are there any HOBBIES OR SPORTS THAT YOU NEVER CONSIDERED BECAUSE YOU HAVE ALWAYS BEEN OVERWEIGHT? (surfing? Kite surfing? Swimming? Rockclimbing? Para-sailing? Bungee jumping? Running a marathon? Entering a fitness contest?)
7 Do you volunteer your time or are you passionate about giving back to any specific organizations? Or if you had the time, who would you donate your time and money to and why? IF YOU WAKE UP TOMORROW AND YOU ARE AT YOUR IDEAL WEIGHT.TELL US, YOUR THIN PERSON BUCKET LIST OF ALL THE THINGS YOU WILL BE DOING - INCLUDE AT LEAST 6 IF I LOSE WEIGHT, I WILL. Have you missed family functions, business events of fun excursions with your friends because of weight or perhaps just hid in the background?
8 DO YOU BELIEVE you you been under estimated in job, personal life, achievements or activities because of your weight? WHAT ARE YOUR GREATEST ACCOMPLISHMENTS IN YOUR LIFE? (NOT YOUR JOB) ARE THERE ANY PHOTOS THAT YOU WOULD WANT RETAKEN IF YOU WERE AT YOUR IDEAL WEIGHT FROM IMPORTANT EVENTS IN YOUR LIFE? (wedding, family events, reunions)? WHAT DO YOU DO IN YOUR FREE TIME IF YOU HAVE A FEW HOURS OR A FEW DAYS OFF? What would you do if you were at your ideal weight and you had free time? WHAT IS YOUR GUILTY PLEASURE FOOD? HOW OFTEN DO YOU EAT IT AND WHEN?
9 GIVE US A DAILY EXAMPLE OF EVERYTHING YOU EAT FROM MORNING UNTIL EVENING. Do you eat differently at home and at work? Describe LIST 3 POSITIVE ADJECITIVES TO DESCRIBE YOU: DID YOU OVERCOMPENSATE in your life with your personality because of your weight? Describe Do ppl tell you oh my gosh you have such a pretty face but Describe WHO WERE YOU IN HIGHSCHOOL? Jock? Cheerleader? Quiet? In the band? On the student council? Do you smoke? How much? How long have you been smoking? Do you drink? How much? How long have you been drinking? Have you had plastic surgery? If so, Describe
10 HAVE YOU EVER BEEN TREATED FOR ANY SERIOUS PHYSICAL OR MENTAL ILLNESS(ES) OR HAD ANY SERIOUS INJURIES? If so Describe ARE YOU ON ANY PRESCRIPTION MEDICATION THAT YOU TAKE ON A REGULAR BASIS? If so, What and for how long? Do you have any personal restrictions if chosen to be on the show? If so Describe Do you have any allergies or medical conditions? If so Describe Do you have any physical conditions or special needs that we should know about? If so Describe Have you ever been arrested? If so describe even if you were released and not charged Have you ever had a restraining order against you? Describe when and why? Have you ever been CHARGED with a crime (misdemeanor or felony)? Describe We are not referring to parking tickets or speeding tickets Do you have any friends or family applying to be on this show? Their names? Relationship to you? Have you ever been party to a lawsuit? Details
11 If chosen to be a participant on THE CULINARY WEIGHTLOSS SHOW (working title) is there any person/persons part of your life that you would prefer not to share on camera (Co-workers, Boss, Family members, Friends, organizations that you attend regularly?)why? List 3 Great friends in the US that we can call as character references who know you for a long time. Include Name and Tel and relationship to you. Please include at least one that is family and one that is not family Please application & Photos to: Culinaryweightlosscasting@gmail.com PLEASE INCLUDE AT LEAST ONE FULL LENGTH & AT LEAST ONE CLOSE UP RECENT PHOTO PLEASE INCLUDE ONE PHOTO FROM YOUR PAST AT YOUR IDEAL WEIGHT IF YOU HAVE ANY Producers reserves the right to modify or add to these eligibility requirements
Admission Forms. Texas Bible College 3900 College Drive Lufkin, Texas 75901. Office (936) 633-7799 Fax (936) 699-2600
Admission Forms Texas Bible College 3900 College Drive Lufkin, Texas 75901 Office (936) 633-7799 Fax (936) 699-2600 Steps for Admission: Step 1: Complete the Application for Admission. Step 2: Mail the
PARTICIPANT APPLICATION & RELEASE EXTREME WEIGHT LOSS (the PROGRAM ) - SEASON 6
PARTICIPANT APPLICATION & RELEASE EXTREME WEIGHT LOSS (the PROGRAM ) - SEASON 6 1. Please fill out this application legibly with either a blue or black pen. 2. Both you and your partner (if applicable)
POTENTIAL CLIENT INTAKE SHEET - PREMISES LIABILITY IMPORTANT
POTENTIAL CLIENT INTAKE SHEET - PREMISES LIABILITY Date: Lawyer: Date of Accident: I. CLIENT INFORMATION Client Name: First Middle Last Date of Birth: You would be preferred to be called (nickname): If
POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT IMPORTANT
POTENTIAL CLIENT INTAKE SHEET - AUTO ACCIDENT Date: Lawyer: Date of Accident: I. CLIENT INFORMATION Client Name: First Middle Last Date of Birth: You would be preferred to be called (nickname): Gender:
Background Questionnaire for Diaconate Aspirants and Wives
Background Questionnaire for Diaconate Aspirants and Wives After you submit this form, click on "Home" and then my website link to return to my website to complete more forms. General Information Date
**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!
Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered.
JENNIFER TARDELLI, MA, LPC, NCC PSYCHOTHERAPY WOMEN S ISSUES
Personal History/Life Script Questionnaire What is your main reason for coming into therapy? What is your difficulty or personal problem? Give a recent example of when and how this problem occurred and
41. Name and address of your physician:
Providence Biblical Counseling Ministry - Personal Data Inventory Identification Data: 1. Name: 2. Phone: 3. Date: 4. Address/City/Zip: 5. Occupation: 6. Business Phone: 7. Cell Phone: 8. Email: 9. Birth
All- Star Academy Casting Application
All- Star Academy Casting Application Please fill out this application legibly with either a blue or black pen. Answer all questions honestly and to the best of your ability. Please write only on the printed
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons
PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION
Mona Mikael, Psy.D., PSY 25089 Neuro- Rehabilitation Psychologist Neuro- Rehab Psychological Consultation & Treatment 630 S. Raymond Ave., #340 Pasadena, CA 91105 626-710- 7838 Web: www.neurorehabtlc.com
Potomac Valley Chiropractic Personal Injury
Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------
Health History and Review of Systems (Please check all that apply)
Health History and Review of Systems (Please check all that apply) Last Name: First Name: Date of Birth: / / q Male q Female Age: Marital Status: q Single q Married q Divorced q Separated q Widowed Who
Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:
Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Holistic Chiropractic and Craniosacral Therapy. Rosewood Family Healing Center - Dr. Maura Moynihan
Holistic Chiropractic and Craniosacral Therapy Rosewood Family Healing Center - Dr. Maura Moynihan Print Name Date Email Date of Birth Age Phone Number Marital Status- M D S W Occupation # of hours/day
ATLANTA SPEECH SCHOOL 3160 NORTHSIDE PARKWAY, NW ATLANTA, GA 30327 404-233-5332 APPLICATION AND CASE HISTORY QUESTIONNAIRE SUMMER PROGRAMS
ATLANTA SPEECH SCHOOL 3160 RTHSIDE PARKWAY, NW ATLANTA, GA 30327 404-233-5332 APPLICATION AND CASE HISTORY QUESTIONNAIRE SUMMER PROGRAMS DATE: CHILD S NAME: BIRTH DATE: S. S. # PARENTS: ADDRESS: TELEPHONE:
Rahab s Rope Application Instructions:
We are so excited to have you join our work in India. The first step in the process for any volunteer is to fill out the following application in full. Rahab s Rope Application Instructions: Complete the
How To Be A Women'S Pastor At Community Bible Church
Pastor Spotlight Martha Fisher, CBC Women s Pastor Inspiration Martha Fisher, Women s Pastor at Community Bible Church, leads with a passion to reach, teach and help the women of our community for Jesus.
Memorial Hospital Sleep Center. Rock Springs, Wyoming 82901. Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am)
Memorial Hospital Sleep Center Rock Springs, Wyoming 82901 Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am) Office Phone: 307-352- 8390 (Mon Fri 8:00 am 4:00 pm ) Patient Name: Sex Age Date Occupation:
NEUROPSYCHOLOGY QUESTIONNAIRE. (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Home address:
NEUROPSYCHOLOGY QUESTIONNAIRE (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Date of birth: Age: _ Home address: _ Home phone: Cell phone: Work phone:
Season 6 - Contestant Application
Season 6 - Contestant Application 1. You must be 18 years or older on January 1, 2015. 2. You must be a citizen or legal permanent resident of the United States. 3. You cannot currently work as a professional
Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-
HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to
Welcome to MELIK s Extended Donor Profile
Welcome to MELIK s Extended Donor Profile MELIK voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening)
Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose
Behavioral Health Consulting Services, LLC
www.bhcsct.org infohealth@bhcsct.org 46 West Avon Road 322 Main St. 530 Middlebury Road Suite 202 Suite 1-G Suite 103 B Avon, CT 06001 Willimantic, CT 06226 Middlebury, CT 06762 Office phone- 1-860-673-0145
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
Social Security # Date of Birth Age. Mailing Address City State Zip Code. Race Gender Height Weight Religious preference
VCU ADMISSION APPLICATION (804) 828-8822 Fax: (804) 828-9879 SERVICE REQUESTED 30-Day Evaluation 15-Day Evaluation Child s Name (please print) Nickname Social Security # Date of Birth Age Mailing CHILD
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
THE CROSSNORE SCHOOL ADOPTION PLACEMENT PROGRAM. Every child deserves a Forever Family ADOPTIVE HOME APPLICATION
THE CROSSNORE SCHOOL ADOPTION PLACEMENT PROGRAM Every child deserves a Forever Family ADOPTIVE HOME APPLICATION The Crossnore School PO Box 249 Crossnore, NC 28616 Phone: (828)733-4305 Fax: 733-1704 Website:
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
City: County: State: Zip:
DATE: BAILEY & GALYEN ATTORNEYS AT LAW Name DOB: Sex: M F Last Name First Middle Maiden Place of birth Country Social Security Number: Drivers License Number: State Address: Apt. # City: County: State:
Rules & Regulations Treasure Mountain Festival s Queen/Teen/Preteen/Ms. Pageant
Rules & Regulations Treasure Mountain Festival s Queen/Teen/Preteen/Ms. Pageant 1. Queen Contestants must be 16 by September 1, 2016 and not have reached her 22 nd birthday on or before January 1, 2017,
Welcome to PASCAL s Extended Donor Profile
Welcome to PASCAL s Extended Donor Profile PASCAL voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General information and characteristics
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
Grace Biblical Counseling Ministry
Grace Biblical Counseling Ministry Personal Data Inventory Name Address Sex: Age: Date of Birth: Phone Number: Highest Education: High School GED College Graduate Post Graduate Other Education or Training
HIGH MIDDLE SCHOOL SCHOOL MINISTRY. volunteer application
HIGH SCHOOL MIDDLE SCHOOL MINISTRY volunteer application Are you in? Students have a lot of questions, like who are my friends? How can I get along with my parents? What am I going to do when I grow up?
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist
1 Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist Adult Questionnaire Patient Name: Date: Street Address: City, State: Zip Code: Home Phone: Work Phone: Cell Phone: Best Number to reach
Answering Questions about Your Family When Applying for Health Insurance
What You Need to Know about Health Insurance Applying for Health Insurance Answering Questions about Your Family When Applying for Health Insurance About this fact sheet You may be able to get financial
Parenting. Coping with A Parent s Problem Drug or Alcohol Use. For children. aged 6 to 12
Parenting Positively Coping with A Parent s Problem Drug or Alcohol Use For children aged 6 to 12 The information in this booklet is meant to help children who are living with harmful parental drug or
APPLICATION FOR ADMISSION Adult Care Facility/Assisted Living Program
APPLICATION FOR ADMISSION Adult Care Facility/Assisted Living Program The Fairport Baptist Homes (FBH) is very pleased to be able to offer an Adult Care Facility (ACF) and Assisted Living Program (ALP)
Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name. Nicknames: Social Security #: - - Current address: Apt #:
Parent Questionnaire Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name Nicknames: Social Security #: - - Current address: Apt #: City: State: Zip Code: Home Phone: Cell/Other #: Parent
2014 PERSONAL HISTORY QUESTIONNAIRE
Department of Safety and Security 6054 South Drexel Avenue Chicago, Illinois 60637 2014 PERSONAL HISTORY QUESTIONNAIRE Applicant Name: Instructions Applicants for police officer positions at The University
OK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
Garland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
Santa Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
Questions Concerning Activities of Daily Living (ADL)
Questions Concerning Activities of Daily Living (ADL) Please fill out this form carefully and mark only one box for each question. 1. How well can you perform personal self care activities including washing,
Child Abduction Unit Request for Investigation Summary
JESUS RODRIGUEZ ASSISTANT DISTRICT ATTORNEY OFFICE OF THE DISTRICT ATTORNEY COUNTY OF SAN DIEGO BONNIE M. DUMANIS DISTRICT ATTORNEY Child Abduction Unit Request for Investigation Summary San Diego 330
EDINA HIGH SCHOOL QUESTIONNAIRE FOR SCHOOL/COUNSELOR RECOMMENDATION CLASS OF 2016
EDINA HIGH SCHOOL QUESTIONNAIRE FOR SCHOOL/COUNSELOR RECOMMENDATION CLASS OF 2016 To assist your counselor in preparing your college recommendation, please complete this questionnaire. The quality of information
IN A SMALL PART OF THE CITY WEST OF
p T h e L a s t L e a f IN A SMALL PART OF THE CITY WEST OF Washington Square, the streets have gone wild. They turn in different directions. They are broken into small pieces called places. One street
Welcome to SPINO s Extended Donor Profile
Welcome to SPINO s Extended Donor Profile SPINO voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
Estover Surgery New Patient Questionnaire
Date of Completion: Personal Details Title: Mr Mrs Miss Ms Dr Other (please circle) Name: Date of Birth: Mobile Number: Home Telephone Number: Work Telephone Number: Contact Email Address: Marital Status:
PERSONAL COACHING AGREEMENT
PERSONAL COACHING AGREEMENT Full Name:_ Nickname (if any): Mailing Address: Work Phone: Cell Phone: Home Phone: Fax: E-Mail Address:_ Website(s):_ Date of Birth: Marital Status: Significant Other's Name:
Recovery Services of Northwest Ohio, Inc.
Recovery Services of rthwest Ohio, Inc. 200 Van Gundy Drive Phone: 419-636-0410 Bryan Ohio 43506 Fax: 419-636-6510 Driver Intervention Program Intake/Screening Interview Name Address Street Social Security.
*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****
SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDER UNIT Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth,
AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224
AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 For AHL Home Office use only tes EVIDENCE OF INSURABILITY AND ENROLLMENT FORM Check appropriate
I Can Bike Information about the program
I Can Bike Information about the program I Can Bike is a not-for-profit organization whose mission is to teach individuals with disabilities to ride a conventional two wheel bicycle and become lifelong
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
METRO MENTORING. Mentor Application
Mentor Application Personal Information Name: Date: City: State: Zip: Home phone: Work phone: Cell phone: Email Address: Social Sec. #: Date of Birth / / Age: Gender: Male Female Ethnicity: White: Hispanic:
Part 1- Host Family Composition
Part 1- Host Family Composition Thank you for applying to be a host family for Fredericksburg Academy! Please be sure to fill in all applicable fields. Please be sure to enter the preferred email address
*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****
SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDERS Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth, Texas
FURR & HENSHAW PERSONAL INJURY INTAKE SHEET. [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed
![FURR & HENSHAW PERSONAL INJURY INTAKE SHEET. [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed](/thumbs/27/9468527.jpg "FURR & HENSHAW PERSONAL INJURY INTAKE SHEET. [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed")
FURR & HENSHAW MYRTLE BEACH OFFICE: 1900 Oak Street, P.O. Box 2909, Myrtle Beach, SC 29578 (843) 626-7621 COLUMBIA OFFICE: 1534 Blanding Street, Columbia, SC 29201 (803) 252-4050 PLAINTIFF INFORMATION
SEA SHEPHERD VOLUNTEER CREW APPLICATION
SEA SHEPHERD VOLUNTEER CREW APPLICATION Thank you for inquiring about crewing with Sea Shepherd Conservation Society! We have had people of all ages, from diverse walks of life, from around the world apply
Depression. What Causes Depression?
National Institute on Aging AgePage Depression Everyone feels blue now and then. It s part of life. But, if you no longer enjoy activities that you usually like, you may have a more serious problem. Feeling
Instructions for Filing a Claim
Instructions for Filing a Claim 1 OF 5 If the claim form is not completed in full, processing of benefits will be delayed until all required information has been received. However, if any questions are
WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
ACCELERATED REHABILITATIVE DISPOSITION APPLICATION
OFFICE OF THE WARREN COUNTY DISTRICT ATTORNEY WARREN COUNTY COURT HOUSE 204 Fourth Avenue WARREN, PENNSYLVANIA 16365 Phone 814-728-3460 FAX 814-728-3483 ACCELERATED REHABILITATIVE DISPOSITION APPLICATION
Neuropsychological Testing Appointment
Neuropsychological Testing Appointment Steven A. Rogers, PhD Kathleen D. Tingus, PhD 1701 Solar Drive, Suite 140 Oxnard, CA 93030 When will it be? Date: Time: Examiner: What will I have to do? Each appointment
ADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Sleep Disorders Center 505-820-5363 455 St. Michael s Dr. 505-989-6409 fax Santa Fe, New Mexico 87505 QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN:
Sleep Disorders Center 505-820-5363 455 St. Michael s Dr. 505-989-6409 fax Santa Fe, New Mexico 87505 QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: Do you now have or have you had:
1 MEMBER INFORMATION Policy No. MZ0909533H0000A
Group Term Life Insurance Application Underwritten by Monumental Life Insurance Company, Cedar Rapids, IA Please complete the entire application. Print clearly in dark ink and mail to: Group Term Life
Getting together. Present simple 1. New Year in Vietnam. Reading: Everybody s birthday. Word focus: Special occasions
2 A Present simple 1 B Present simple: questions C Communication strategies Showing interest D Interaction Are you a people person? Getting together Present simple 1 Word focus: Special occasions 1 Work
What is Safeguarding?
What is Safeguarding? Easy read 2011 All images CHANGE http://www.changepeople.co.uk/ 1 Message from CHANGE We hope that you find this document useful to support people with learning disabilities and other
Welcome to AEROZ s Extended Donor Profile
Welcome to AEROZ s Extended Donor Profile AEROZ voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General information and characteristics
NORTHERN DISTRICT OF CALIFORNIA U.S. PROBATION OFFICE PRESENTENCE INTERVIEW FORM. Atty Present?: 9 YES 9 NO Interpreter: 9 YES 9 NO
PROB 1A (ND/CA 11/10) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA U.S. PROBATION OFFICE PRESENTENCE INTERVIEW FORM THIS SECTION TO BE COMPLETED BY U.S. PROBATION OFFICE Date of Interview:
INTAKE FORM. General Information Name DOB Date Address: Phone: Cell Phone: Email:
INTAKE FORM General Information Name DOB Date Address: Phone: Cell Phone: Email: Marital Status (Circle One) Single Engaged Married Separated Divorced Widowed If married how long? Number of previous marriages
Your Results. For more information visit: www.sutton.gov.uk/healthchecks. Name: Date: In partnership with
Your Results Name: Date: For more information visit: www.sutton.gov.uk/healthchecks In partnership with Introduction Everyone is at risk of developing diabetes, heart disease, kidney disease, stroke and
History Questionnaire
History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what
INFORMATION ABOUT YOU
NOTE: With this type of form, to be completed by the client you would want the top portion to approximate your letterhead in case someone picked up this form for another to complete or some other reason
12 Step Goal-Setting Process
12 Step Goal-Setting Process 1 Decide exactly what you want in every key area of your life. Start off by Idealizing. Imagine that there are no limitations on what you can be, have or do. Imagine that you
PERSONAL LIFE HISTORY BOOKLET of. Place a photograph of the person here and write his/her name on the line below
PERSONAL LIFE HISTORY BOOKLET of Place a photograph of the person here and write his/her name on the line below This booklet details the life of Preferred Name: Original language Language now spoken Prepared
REHAB XCEL, LLC. NEW PATIENT INFORMATION
REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
Using Motivational Interviewing to Improve Clinical Outcomes
Using Motivational Interviewing to Improve Clinical Outcomes BARBARA B. WALKER, PH. D. NATIONAL JEWISH HEALTH DENVER, COLORADO BBWALKER@INDIANA.EDU Overview Why MI? What exactly is MI? Spirit Principles
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com Client Information Date: Name: Preferred First Name: Date of Birth: / / SSN: - - Address:
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM Personal Information Date: Name: Phone #: Cell #: May we leave a message on these numbers?: Best time to reach me
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
Wake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587
Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor
Arrive 15 minutes before your scheduled appointment time.
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
PROGRAM DESCRIPTION ELIGIBLE PARTICIPANTS
PROGRAM DESCRIPTION MC Workshops Residential is a Christ-based reentry home for men located in Hartville, Ohio. MC Workshops Residential provides housing, board, Christian coaching and employment training
DUI CLIENT INTERVIEW SHEET
DUI CLIENT INTERVIEW SHEET Date: I. PERSONAL INFORMATION Full Name: Age: DOB: Race: Sex: Referred by: Current Address: City: State: Telephone Number(s): (H) (W) (C) (O) How long resident of county: Marital
Young people and drugs
Young people and drugs Many parents worry about whether their son or daughter is taking illegal drugs, how they can tell, and what to do about it. While there s a lot of concern about illegal drugs in
Scholarship application deadline: April 15, 2014
THE KIWANIS CLUB OF ABILENE FOUNDATION, INC. 473 CYPRESS ST., SUITE 107, ABILENE, TX 79601 (325) 673-1341 Building One Child and One Community at a Time Scholarship application deadline: April 15, 2014
Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS
Borgess Diabetes Center PATIENT REGISTRATION/DEMOGRAPHICS Please complete the following form by filling in the blanks or by circling the answer provided. Last Name: First Name M.I. Address: City, State,
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.org EDWARD H. MARTIN, M.A., LPC.. MARLA S. FREEMAN, M.A.
DEVELOPMENTAL SPEECH AND LANGUAGE HISTORY
DEVELOPMENTAL SPEECH AND LANGUAGE HISTORY Parents: This history may appear to be quite long. However, a number of the questions require checking off responses, which can be done quickly. This information
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
TUITION RATES SCHOOL YEAR 2015-2016
TUITION RATES SCHOOL YEAR 2015-2016 REGISTRATION FEE: $65.00 per child DISCOUNTS: Family discount apply to families with two or more children in the Extended Day program. Full price is paid for the youngest
MOST FREQUENTLY ASKED INTERVIEW QUESTIONS. 1. Why don t you tell me about yourself? 2. Why should I hire you?
MOST FREQUENTLY ASKED INTERVIEW QUESTIONS 1. Why don t you tell me about yourself? The interviewer does not want to know your life history! He or she wants you to tell how your background relates to doing