Consultation Request Form

Literacy Dr, LLC Consultation Request Form

Literacy Dr provides free, 1-hr phone consultations for families to discuss their student's needs and learn more about our services. Consultations are held via phone with Dr. Jennifer Petrich. NOTE: This form will ask you to upload copies of any evaluations you wish Dr. Petrich to review prior to your consultation. Uploading an evaluation is optional.

Student Information

In the first section of the form, you will be asked to enter student information. Parent/Caregiver information will be gathered in section 2.
How many students will you be completing this form for?*

Student 1
Student 1: Please provide a brief description of why you are seeking a consult for your student.*
Student 1: Name*

First NameLast Name
Student 1: Date of birth*

MonthDayYear
Student 1: Grade for the 2023/24 school year
Student 1: Grade for the 2024/25 school year*
Student 1 Diagnoses: Does your student have any diagnoses?*
Student 1: Please list any diagnoses
Student 1: Are you able to provide copies of evaluations?*

YesNo
Please upload copies of any evaluations you wish Dr. Petrich to review.*

Cancelof

Student 2
Student 2: Please provide a brief description of why you are seeking a consult for your student.*
Student 2: Name*

First NameLast Name
Student 2: Date of birth*

MonthDayYear
Student 2: Grade for the 2023/24 school year*
Student 2: Grade for the 2024/25 school year*
Student 2 Diagnoses: Does your student have any diagnoses?*
Student 2: Please list any diagnoses
Student 2: Are you able to provide copies of evaluations?*

YesNo
Please upload copies of any evaluations you wish Dr. Petrich to review.*

Cancelof
How did you hear about Literacy Dr?*
How did you hear about Literacy Dr?*
Which platform did you hear about us on?*
Please enter the name of the Facebook page*
Please enter the name of the Facebook group*
Please enter the name of the person who referred you. *
How did you find us?*
(Optional) Please enter any additional comments here

Parent/Caregiver Information

This section of the form is to gather information on the parent(s)/caregiver(s) who will be receiving the free consultation with Dr. Jennifer Petrich.
Will more than one parent/caregiver be attending the free consultation?*

Parent/Caregiver 1: Name*

First NameLast Name
Parent/Caregiver 1: Relationship to student*
Parent/Caregiver 1: Email*
example@example.com
Parent/Caregiver 1: Time Zone*
Parent/Caregiver 1: Country of residence*
Parent/Caregiver 1: State (U.S. Residents)*
Parent/Caregiver 1: Phone Number (U.S. Residents)*
Please enter a valid phone number.
Would you like to conduct the free consultation via a different phone number than the one entered above?*
Alternate number if consultation should be conducted from a different number*
Please enter a valid phone number.
An important message for our Canadian clients:

Although initial consultations are a free service provided by Literacy Dr, provision of paid services to Canadian clients requires that Canadian clients use either:
- a debit card, or
- a credit card authorized to make US transactions
We advise checking with your bank to confirm any possible international fees that may come with debit/credit payments to the United States.
Please click here to confirm that you have read and understood the above requirements:*

I have read and understood the above requirements for Canadian clients receiving paid services by Literacy Dr.
Province (Canadian residents)*
Phone Number (Canadian residents)*
Please enter a valid phone number.
Alternate number if consultation should be conducted from a different number
Please enter a valid phone number.
Phone Number*

Country CodeArea CodePhone Number
Parent/Caregiver 2: Name*

First NameLast Name
Parent/Caregiver 2: Relationship to student*
Parent/Caregiver 2: Email*
example@example.com
Parent/Caregiver 2: Time Zone*
Should be Empty:

Literacy Dr, LLC Consultation Request Form

Student Information

Student 1

Student 2

Parent/Caregiver Information