Literacy/Learning Disabilities/Dyslexia Form

Literacy/Learning Disabilities/Dyslexia

Complete this form ONLY if you are requesting an evaluation or therapy for learning disabilities/dyslexia!

Speak English: YesNo

Which of these or you most concerned about? (Please check all that apply by holding control key)

Other

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?
YesNo

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)

IN ORDER FOR YOUR APPLICATION TO BE COMPLETE, YOU MUST PROVIDE ALL PREVIOUS TEST SCORES, SUCH AS ACHIEVEMENT TESTS