Intake form

Name

Message

Child’s Name, Age, and Date Of Birth *

Reason for pursing educational therapy

In which city are you located?

Has your child been evaluated for learning disabilities?

If so, please provide a description of the Diagnosis below

Has your child’s hearing and vision been evaluated? If so, what was the date of their last evaluation?

Current Academic Strenghts

Current Academic Difficulties

What does your child enjoy doing in their free time?

What motivates your child ?

What upsets your child ?

What are three words that could be used to describe your child?

intake form