Reading Form

    Reading Form

    Your Name (required)

    Your Email (required)

    My child is between the ages of (required)

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

    If yes please list:

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

    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)

    If yes by whom and what were the results:

    My child currently receives additional services:(required)

    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)