Reading Form

Your Name (required)

Your Email (required)

My child is between the ages of (required)
4-67-910-1213+

My child has a relevant medical/educational diagnosis: (required)
YesNo

If yes please list:

My child has a history of a speech and/or language delay: (required)
YesNo

The following individuals have expressed concerns over my child’s fine motor/sensory skills: (required)
DoctorTeacherMyselfFamily member (grandparents, aunts, uncles, etc.)Other

My child has recently been evaluated: (required)
YesNo

If yes by whom and what were the results:

My child currently receives additional services:(required)
YesNo

If yes please provide list of current services:

A few specific concerns I have regarding my child’s literacy skills include:

My level of concerns regarding my child’s fine motor and/or sensory development is: (required)
Minimal, I am not overly concernedMarginal, I am somewhat concernedUrgent, I am very concerned

Please list the best dates/times for us to call: (required)