Inquiry Form
Your name
*
Child's name
*
Your email
*
Phone Number
*
How did you hear about LGR?
Referral
Search engine
Word of mouth
Ad
Referred by
Reason for referral
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School child attends
Grade
Teacher name
Teacher email
Ok to contact?
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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?
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
Family History (If relevant)
Submit
Should be Empty: