Dyslexia Assessment Contact Form

If you would like, please fill out the form below. The information that you provide will be submitted directly to Dr. Mano.
Parent's Name

First NameLast Name
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Child's Age
Child's Grade
Parent's Phone Number
Please enter a valid phone number.
Parent's Email
example@example.com
What area(s) of academic functioning are you concerned about (check all that apply)?

PhonicsWord RecognitionReading ComprehensionReading FluencySpelling
How long have you noticed these problems?
Any history of academic intervention and/or tutoring? If so, please explain.
Does your child have any history of attention and/or behavioral problems (e.g., ADHD)?
Does your child have any history of traumatic brain injury?
Does your child have any history of neurological conditions (e.g., epilepsy)?
Has your child passed vision and hearing exams?
Any history of medical issues or developmental delays?
Any complications during pregnancy and/or delivery?
Have you retained legal counsel related to school functioning?
Has your child received any tutoring to address your concerns? If so, please describe.
Has your child been previously tested for learning difficulties (either at school or by a professional)? If so, please describe.
Click here to indicate that you consent to allow the information within this form to be emailed directly to Dr. Mano. Clicking here also indicates that you understand that this information is confidential and that Dr. Mano will review this information and have clinic staff contact you directly, as appropriate, to discuss clinic services and scheduling options.

I consent
Confirm the following:*

I confirm that my child's first language is English.I confirm that my child is in the 3rd grade or above.I confirm that my child has received some tutoring or academic intervention for reading.I confirm that there are currently no speech issues that prevent language and reading testing.I confirm that there are no concerns related to autism spectrum disorder.I confirm that I have not retained legal counsel related to school functioning.
Please verify that you are human*
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