____Associates of Springfield Psychological____                                                                                    
920 West Chester Pike                1489 Baltimore Pike                    709 E. Gay Street                                                                                        
      Havertown, PA 19083                    Bldg. 200, Suite 250                    West Chester, PA 19380                                                                                        
Springfield, PA 19064                                                                                        
Telephone: 610-544-2110                                                                                        
Fax: 610-604-9510                                                                                        

REQUEST FOR TRUANCY PROGRAM                                                                                        

Welcome to the Associates of Springfield Psychological truancy program. This program has been designed
to help you and your child gain a better understanding of some of their difficulties and how you can
work together to help correct some of the truancy problems. Some areas to be covered are communication,
decision making, and responsibility for one's choices.


I agree to enter into the truancy program run by Associates of Springfield Psychological.


NAME OF STUDENT:_____________________________________________________________

ADDRESS:______________________________________________________________________

TELEPHONE: (day/parent)_______________________ (evening)___________________________

SCHOOL DISTRICT:______________________________________________________________

GRADE:_________ SCHOOL:_______________________________________________________

PARENT(S) NAME:_______________________________________________________________

PARENT(S) ADDERSS:____________________________________________________________

Description of truancy problem:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Who referred you to the Truancy Program?______________________________________________

Title of person referring:____________________________________________________________

Parent Signature:_________________________________________________________________

Student Signature:________________________________________________________________