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)
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)
