Complete this form ONLY if you are requesting an evaluation or therapy for learning disabilities/dyslexia!
Which of these or you most concerned about? (Please check all that apply by holding control key)ReadingSpellingMathHandwritingWriting StoriesDistractabilityConcentrationFocusTemper/AngerHyperactivitySocial SkillsSadnessWorryMoodinessArguesSuicidal TendenciesGets in TroubleOther (please list below)
Have you ever been to a school meeting for your child to receive help?
Does your child receive special help at school or has he/she in the past?
Please check all that apply:
Is there a plan for your child to be tested by the school or another private agency?
Has your child seen a doctor about attention or behavioral problems?
Has your child taken medicine to help with attention or behavioral problems?
If, yes please list the medicine and the age your child first started the medicine:
Does your child any medical diagnoses? (Please check all that apply)
ADHD/ADDBipolar DisorderAllergiesCerebral PalsyAutismCleft Palette/Cleft LipConduct DisorderDepressionDevelopmental DelayObsessive Compulsive DisFragile XFetal Alcohol SyndromePDDSeizure Disorder
IN ORDER FOR YOUR APPLICATION TO BE COMPLETE, YOU MUST PROVIDE ALL PREVIOUS TEST SCORES, SUCH AS ACHIEVEMENT TESTS