Request for Services

Thank you for your interest in the Dyslexia Resource Center. Please complete the form below as completely as possible and click SUBMIT. This gives us the information needed to make initial recommendations based on your specific circumstances. Once we have received your completed Request for Services form, we will be in contact within three business days.

We understand that you are concerned about your child! We make every effort to get back in touch with you as soon as possible. If you are concerned we did not receive your form, please email us at info@dyslexiasc.org.

What Services are you Interested In *
GENERAL INFORMATION
Child's Name *
Child's Name
Gender
Birthdate *
Birthdate
Parent/Guardian's Name *
Parent/Guardian's Name
Best Contact Number *
Best Contact Number
Mailing Address *
Mailing Address
YOUR CHILD'S ACADEMIC HISTORY
Homeschooled? *
Does your child have
Check all that apply
YOUR CHILD'S HEALTH HISTORY
Food? Other? Asthma?
Please list number of people and their relationship to the family.
Parent and/or teacher's observations:
Both at home and at school:
This FREE workshop is offered quarterly at the Dyslexia Resource Center. Visit www.dyslexiasc.org/training to register.
Notice of Electronic Communications *
We frequently use email as an efficient way to communicate with families we serve. This includes, but is not limited to, managing requests for services, scholarships and appointments, communicating progress regarding your child's skills, and sharing assessment reports. Standard e-mail services such as Gmail, Hotmail, etc. are not encrypted and can be intercepted and read by unauthorized individuals. We will do our best to ensure that we have your correct email address and ask that you do the same. Please acknowledge below if you agree to communicate electronically with The Dyslexia Resource Center.