18 and Under Intake and Screening Intake and Screening Student First Name * Student Last Name * Parent First Name * Parent Last Name * Parent Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Student Date of Birth * Student School Name * Referred By Reason for Request Home Phone * Cell Phone Work Phone Number of household members Annual Household Income * Is there a history of learning difficulties in the family? Yes No Is this child enrolled in school? Yes No Child's Current Grade Has the child repeated a grade? Yes No If so, which grade? Does the child receive extra help in reading at school? Yes No How Would You Rate Your Child's... School Grades Poor Good School Attendance Poor Good School Attitude Poor Fair Good School Conduct Poor Fair Good Reading Is your child experiencing reading difficulty? Yes No Does your child know their letter sounds? Yes No Is your child able to decode? Yes No Does your child reverse letters when reading? Yes No Does your child transpose letters when reading? Yes No Is your child able to blend letter sounds? Yes No Writing and Spelling Does your child experience problems writing? Yes No Is your child's writing legible? Yes No Does your child have problems spelling? Yes No Can your child write in both print and cursive? Yes No Speech Does your child have speech problems? Yes No Has your child ever received speech or language services? Yes No Does your child have hearing problems? Yes No Does your child have vision problems? Yes No Which hand does your child prefer to write with? L R Either Health Does your child have any allergies? Yes No If so, explain Has your child been diagnosed with ADD or ADHD? Yes No Are there any medical conditions we should be aware of? Yes No If so, list conditions Has your child had any psychological or psychiatric evaluations? Yes No If yes, when and where Has your child ever had lead poisoning? Yes No Is the child on any medications? Yes No If yes, list medications If you are human, leave this field blank. Submit
