FREE ONLINE READING ASSESSMENT
Submitting this short form (5 minutes or less) ensures that your child will be scheduled for their free reading assessment (including an optional dyslexia screening), your parent consultation (by appointment only), and helps me to prepare for it. Please note that assessments and reading lessons are held virtually on Zoom. If you have more than one child, please submit a separate form for each child.
Child's Name
*
First Name or Initial
Middle Name or Initial
Last Name
Child's Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2024
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Year
Child's Grade
*
If known, please include their reading grade level EX: grade 4 / level 2
What school does your child attend? (optional)
Type/level of schooling.
*
Homeschool
Private School
Public School
Charter School
Pre-school
Not in school
Other
In a few words, tell me about your child's reading challenges and needs. What are their most challenging areas when it comes to reading/literacy? (Ex: letter sounds or recognition, sight word recognition, phonemic awareness, fluency, reading comprehension, vocabulary, reading with confidence, etc.) This is also for parents who have a child under 5 who needs to learn the fundamental skills.
*
Does your child have any diagnoses? (yes or no)
*
Do you want your child to take the optional dyslexia screener? (Depending on their results, I suggest having them tested by a licensed educational psychologist, neurologist, or other qualified professional.)
Yes
No
I will decide on the day of the assessment
Does your child have an IEP or a 504 Plan?
*
Yes
No
What reading level did your child's classroom teacher say they are?
*
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Email
*
example@example.com
Child's Email (if applicable)
*
example@example.com
Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian's Telephone Number
*
What is your time zone?
*
Eastern Time
Central Time
Pacific Time
Mountain Time
Other
Select days your child is available for online lessons. Check all that apply. (Sessions days are subject to my current availability)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Select times your child is available for lessons (in your timezone). Check all that apply. Please note: I am in Eastern Standard time. (Sessions times are subject to my current availability) .
*
Morning Weekday
Afternoon Weekday
After school/Evening weekday
What length of time do you expect your child to need lessons?
*
During the entire school year
During the entire school year including the summer
During the summertime only
What type of device(s) will your child be using to attend class? Check all that may apply.
Mac desktop computer
Other desktop computer
MacBook
Other laptop
IPad
Other tablet
Smartphone
Other
Do you have a smart pen?
How did you find me? Check all that apply.
*
I was referred to you
We met in person
At an event (in-person or online)
A Facebook group
A posted flyer
Your website
LinkedIn.com
Nextdoor.com
Tutors.com
Wyzant.com
Google search
Craigslist.com
Care.com
Other
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