* Child's Name
* Parent/Guardian's Name
Best Contact Number
* Best Contact Number
* Mailing Address
Child's Preferred Name (if applicable)
YOUR CHILD'S ACADEMIC HISTORY
If yes, how long?
Other schools? (Please include grades attended)
Has your child been retained? If so, what grade(s)?
Has your child had a formal psycho-educational evaluation? If so, when?
If your child has/had an OG tutor, please provide tutor's name:
Your child's strengths:
Your child's weaknesses:
YOUR CHILD'S HEALTH HISTORY
If a preemie, how early?
Any complications at birth?
Early Developmental Milestones met?
If no, please list those not met:
Ear infections or other conditions that might affect speech, hearing, or development?
List any emotional or behavioral problems:
Food? Other? Asthma?
My child is diagnosed with ADD
My child has been assessed and does NOT have ADD
My child is currently being assessed for ADD
My child exhibits attention deficits but has not been assessed for ADD
My child has no attention deficits
Takes medication for ADD/ADHD?
Please list any medications your child takes regularly:
Does your child wear or need glasses/contacts?
Does your child have any hearing or speech impairments?
Child's Birth Order
Number of adults in the home?
Who else has trouble with reading or spelling?
Why are you concerned about your child's reading/spelling?
Parent and/or teacher's observations:
What are you currently doing to help your child with reading/spelling?
Both at home and at school:
Have you attended a Helpful Hints for Reading workshop?
This FREE workshop is offered quarterly at the Dyslexia Resource Center. Visit www.dyslexiasc.org/training to register.
Yes, I have.
No, I have not.
How did you learn about the Dyslexia Resource Center?
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.
Yes, I agree to electronic communications from the Dyslexia Resource Center.
Thank you for submitting your Request for Services.
You will receive a call from our staff within three business days to follow up.
We look forward to visiting with you!