AZDC INTAKE FORM

AZDC INTAKE FORM
Agreement for Reading Therapy and Screening Services with AZ Dyslexia Center.
Name of Student
Date

MonthDayYear
Date
Name of parents or legal custodian (if student is under age 18)
Primary Contact
Phone Number
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Primary Address
Preferred Email
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Therapy location: AZ Dyslexia Center, 116 N Lindsay Rd. #7, Mesa AZ 85213

We know that everyone learns in his or her unique way. Because of this, AZ Dyslexia Center does not provide outcome guarantees. The amount of reading therapy required for someone with dyslexia, or any struggling reader, depends on many factors. We know that by using the appropriate therapy under the right conditions we can help rewire the brain to allow gains in reading, spelling and writing abilities This therapy is a commitment which could take two years to remediate.
FEES
Our rate for Reading Therapy Service is $80 per session. That session includes 60 minutes of direct time with the student in an individual (not group) session, all materials, preparation for the session, and time for analysis after the session. We do not cut our students sessions short to accomplish any of the above services.

Payment is due at time of service. This may be prepaid per session, weekly or monthly. We accept cash, check, all major credit cards, ESA and HSA. Checks can be made payable to: AZ Dyslexia Center.

Your Reading Specialist is not able to stay beyond the 60-minute session, unless otherwise arranged. You can make an appointment to meet with your specialist at another time if needed.

Dyslexia Screening is $400.
ATTENDANCE
It is imperative that your child attend therapy sessions at least twice a week. We can meet with students for additional time, but not less. Evidence does not support the desired improvement without having the learning opportunity twice a week.

CANCELLATION POLICY
AZ Dyslexia Center strives to provide a successful and rewarding therapy experience. A consistent therapy attendance is beneficial in providing the best chance at achieving treatment goals.

If you need to cancel an appointment, we request a 24-hour notice. If you cancel within less than 24 hours of your scheduled appointment, you may be charged for ½ of the scheduled session. If you do not call to cancel and fail to keep your appointment, you will be charged for the scheduled session.

I have reviewed the above information and acknowledge my agreement:
Print Name
Date

MonthDayYear
Date
Signature

Clear
SCHEDULE
We Will Meet on
Day
Time

Hour Minutes

AM/PM Option
Day
Time

Hour Minutes

AM/PM Option
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Time

Hour Minutes

AM/PM Option
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Time

Hour Minutes

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This agreement may be terminated at any time by any party, within the cancellation policy guidelines above. If you have any questions about this agreement, please discuss them with your Reading Therapist or the Director.
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