Complete this form ONLY if you are requesting an evaluation or therapy for learning disabilities/dyslexia!
Date of Birth:
Speak English: YesNo
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? YesNo
Does your child receive special help at school or has he/she in the past? YesNo
Please check all that apply: TutoringResource SpecialistSpeechESLInclusionO.T.R.
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? YesNo
Has your child taken medicine to help with attention or behavioral problems? YesNo
If, yes please list the medicine and the age your child first started the medicine:
Does your child have any medical diagnoses? (Please check all that apply) ADHD/ADDBipolar DisorderAllergiesCerebral PalsyAutismCleft Palette/Cleft LipConduct DisorderDepressionDevelopmental DelayObsessive Compulsive DisorderFragile XFetal Alcohol SyndromePDDSeizure Disorder
IN ORDER FOR YOUR APPLICATION TO BE COMPLETE, YOU MUST PROVIDE ALL PREVIOUS TEST SCORES, SUCH AS ACHIEVEMENT TESTS