LGR Learning Group LLC Intake Form
Please fill out as much information as you can, or feel comfortable sharing.
Child's name
First Name
Last Name
Child's age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by
First Name
Last Name
Reason for referral
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Parent/caregiver name
First Name
Last Name
Email
example@example.com
Phone number
Please enter a valid phone number.
Other parent/caregiver name
First Name
Last Name
Email
example@example.com
Phone number
Please enter a valid phone number.
Preferred Invoice Recipient Name/ Email/Phone Number
Name(s) and age(s) of sibling(s)
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School child attends
Grade
Teacher name
Teacher email
example@example.com
Teacher phone number
Please enter a valid phone number.
Ok to contact?
Does your child receive or has your child received services from a learning or reading specialist, speech-language pathologist and/or occupational therapist?
If so, please provide type, frequency and start and end dates:
Has your child been evaluated?
If so, please provide type, date and provider’s name:
Does your child have a medical diagnosis or professionally-diagnosed disorder?
Are you child’s hearing and vision exams up-to-date?
Are there any precautions or considerations tutors and therapists should keep in mind when working with your child?
Did your child achieve developmental milestones (crawling, walking, first words, combining words, potty training, etc.) at recommended ages?
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Does your child exhibit any of the following?
Reversing letters
Confusing letters, numbers, and/or words
Difficulty sustaining attention
Disorganization
Behavioral issues
Unusual pencil grip
Trouble writing or copying
Inability to complete work independently and efficiently
Reading comprehension challenges
Poor phonemic awareness
Forgetfulness
Difficulty being understood by others
Limited vocabulary
What are your child's strengths and how does your child seem to learn best?
Preference for intervention:
In-person at home
In-person at convenient location
Remote (teletherapy)
Days/times child is available for tutoring
Monday a.m.
Monday after school and/or evening
Tuesday a.m.
Tuesday after school and/or evening
Wednesday a.m.
Wednesday after school and/or evening
Thursday a.m.
Thursday after school and/or evening
Friday a.m.
Friday after school and/or evening
Weekends
Please let us know some of your child’s interests.
Family History (If relevant)
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Should be Empty: