ADULT _ Prospective Student Information Form

this form is for adult inquiries only!

Please click the ‘request service’ tab if you are seeking services for a child.

Thank you for your interest in the Dyslexia Resource Center. While our center is focused primarily on children with reading difficulties, we regularly receive requests from adults seeking help with reading. We will do everything we can to help you find resources for your situation.

Please complete and submit the form below. Once we have received your completed Prospective Student Information Form, we will be in contact within two business days.

If you are concerned we did not receive your form, please email us at info@dyslexiasc.org.

Your Name *
Your Name
Best Contact Number *
Best Contact Number
Mailing Address *
Mailing Address
Birthdate *
Birthdate
ACADEMIC HISTORY
Select One
I attended school at: *
Check all that apply.
RELEVANT HEALTH HISTORY
Select One
If none, write NONE. If not known, write NOT KNOWN
If none, write NONE
If none, write NONE.
Food? Other? Asthma? If none, write NONE.
If none, write NONE.
Life Impact