Client Contact Form

Client Contact Form
Name of Contact Person*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Individual's name if different from contact name*
Birthday*

MonthDayYear
Date
Age*
Grade*
School, if applicable
I am interested in information for:*
If you are interested in testing or remediation services from The Reading Centers & Cognitive Connections Clinic, please select all concerns from the options below.*

Reading concerns (Dyslexia)Writing concerns/Penmanship (Dysgraphia)Math concerns (Dyscalculia)Attention/Focus (ADD/ADHD)Academics or Cognitive Struggles (IQ)Autism spectrum disorder (ASD)
If you are interested in Cognitive Mediational Therapy, please select all concerns from the options below.

Brain fog / forgetfulnessTask initiationOrganizational skillsWorking memoryFlexibilityAutism or other neurodivisitiesCognitive declineEmotional control and self regulationTime managementImpulsivity or lack of sustainable attentionDementiaSensory concernsOther
Which location are you interested in testing or services from?*

CarencroYoungsville
How did you hear about us?*
Thank you for contacting The Reading Center and Cognitive Connections Clinic! Someone will reach out to you soon.
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