Family Questionnaire
To identify the need for a Dyslexia Assessment and/or Dyslexia Therapy
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Student's Name
*
First Name
Last Name
Student's Grade
*
Student's Birthday
*
-
Month
-
Day
Year
Date
What type of school does your student attend?
Public School
Private or Hybrid School
Home School
Do you have any concerns about your child's work at school?
Yes
No
Has your child had a recent hearing/vision screening?
Yes, hearing
Yes, vision
No
If so, has anything changed?
Has your child received any special instruction or tutoring at school or privately?
Yes
No
If so, please select all that apply.
Gifted/Talented
Tutoring
Reading Instruction
IEP/504
Has your child repeated a grade?
Yes
No
Has your child ever been critically or chronically ill?
Yes
No
Does your child have any physical problems that you feel may cause difficulty in learning?
Yes
No
Does your child seem to have difficulty following directions?
Yes
No
Does your child seem to have more difficulty in reading, writing, and spelling than in most other subjects?
Yes
No
Does your child need a significant amount of help to complete homework?
Yes
No
Does your child enjoy being read to by adults?
Yes
No
Does your child hesitate to read to you?
Yes
No
Does your child dislike and/or avoid reading?
Yes
No
Is reading difficult for any family member (parent, grandparent, etc.)?
Yes
No
Family History: do any of your child's family members have dyslexia?
Yes, Mom and/or Dad
Yes, Grandparent
Yes, sibling
No
Not sure
Are you interested in scheduling a Dyslexia Assessment with us? If yes, we will contact you to discuss.
Yes
No
Please share any additional information below that will be helpful in assessing your needs.
Thank you! We will be reaching out soon!
Submit
Should be Empty: