New Client Registration Form
How did you hear about Reach-ed Learning Solutions?
Google search
From a current/ former client
Dyslexia Support Services website
ADA (Australian Dyslexia Association) website
BetterEducation.com.au
Other tutoring website
Child's full name
Child's Date of Birth
Child's Gender
Child's Preferred Pronouns
Parent/Guardian 1's Name
Parent/Guardian 1's Relationship to the Child
Parent/Guardian 1's Phone Number
Parent/Guardian 1's Home Address
Parent/Guardian 1's Email Address
Parent/Guardian 2's Name (if applicable)
Parent/Guardian 2's Relationship to the Child
Parent/Guardian 2's Phone Number
Parent/Guardian 2's Email Address
Child's Current School Name and address
Child's School Grade/Year level
Does your child have an Individual Learning Plan (ILP)?
Yes
No
ILP no longer in place
Details (if applicable) of the learning goals/areas of focus in the ILP
Does your child have any diagnosis/es? (e.g., dyslexia, ADHD, autism spectrum disorder, etc.)
None
Dyslexia
ADHD
ASD
Specific Learning Difficulties
Dyspraxia
Other
Is your child an NDIS participant? If the answer is NO please skip the next question.
Yes
No
Current Therapies/Interventions (e.g., speech therapy, occupational therapy)
What are your Child's hobbies/ interests?
Learning areas needing support
Reading
Spelling
Executive Functioning
Study/ Organisational Skills
Writing
Additional Comments/Information:
I understand that the information provided will be used confidentially for educational purposes only.
*
Yes
Submit
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