Name * First Name Last Name Email * Child's Name, Age, and Date of Birth * Reason for pursuing educational therapy In which city are you located? Has your child been evaluated for learning disabilities? Yes No 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 Strengths 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? Thank you! I will be reaching out to you soon to develop a plan for giving your child the support they need to succeed!