What service are you interested In?
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Child's Name
*
First Name
Last Name
Gender
School
Grade
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Age
*
Birthdate
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MM
DD
YYYY
Parent/Guardian's Name
*
First Name
Last Name
Best Contact Number
*
(###)
###
####
Email
*
Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's Preferred Name (if applicable)
Homeschooled?
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If yes, how long?
Other schools? (Please include grades attended)
Has your child been retained? If so, what grade(s)?
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Handedness:
*
Select one
Right
Left
Ambidextrous
Has your child had a formal psycho-educational evaluation?
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Select One:
Yes
No
Does your child have
Check all that apply
If your child has/had an OG tutor, please provide tutor's name:
Your child's strengths:
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Your child's weaknesses:
*
List any emotional or behavioral concerns:
ADD/ADHD
*
Select one
My child has no symptoms of ADD and/or ADHD
My child exhibits attention deficits but has not been assessed for ADD or ADHD
My child is diagnosed with ADD and/or ADHD
My child is currently being assessed for ADD and/or ADHD
My child has been assessed and does NOT have ADD or ADHD
Takes medication for ADD/ADHD?
*
Select one
Yes
No
N/A
Does your child wear or need glasses/contacts?
*
Select one:
Yes
No
Does your child have any hearing or speech concerns?
*
Select one
Neither
Speech Only
Hearing Only
Both
If speech impairments exist are speech therapy services being provided?
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Select One:
In the past
Currently
Being evaluated
N/A
If hearing is/has been a concern...
Select all that apply:
Why are you concerned about your child's reading/spelling?
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Parent and/or teacher's observations:
What are you currently doing to help your child with reading/spelling?
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Both at home and at school:
How did you learn about the Dyslexia Resource Center?
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Notice of Electronic Communications
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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.
Name of person financially responsible if other than legal guardian.
First Name
Last Name
Email
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Thank you for submitting your Request for Services.
You will receive a response from our staff within three - five business days to follow up. In order to prevent our communication from landing in your spam account, please consider adding the following emails to your contacts: info@dyslexiasc.org, assessments@dyslexiasc.org, accounting@dyslexiasc.org.
