Initial Appointment Request
I am very excited to learn more about your interests, how we can help, and your journey to get here! So I can be as prepared as possible and to work within schedules, please fill out the information below. Once received, I will email you back with an exact appointment time. Thank you, Whitney Stein, Owner, Dyslexia & ADHD Specialist
Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Student Grade
*
Current or Upcoming Grade
Student Date of Birth
*
-
Month
-
Day
Year
Date
School
*
Phone
*
-
Area Code
Phone Number
Office that is closest to you:
*
Arcadia, Phoenix
Online
Scottsdale
Other
Areas of Need
*
Speech & Language
Dyslexia Remediation & Support
Parent Coaching
General Homework Help
Therapy/Counseling
Handwriting Support
Other
E-mail
*
What days work best for you to schedule an initial phone call?
*
Monday
Tuesday
Wednesday
Thursday
Other
What times work best for you? Please choose 2 times, or offer specific times.
*
9:00-10:00
10:00-11:00
11:00-12:00
12:00-1:00
1:00-2:00
Other
If you have very specific times of availability, please fill that out here. Please note sometimes our schedules have limited availability but we will do our best to get back to you as quick as possible. We know how important these calls can be.
Does your child have testing or a diagnosis?
*
No
Yes
In the process
I need help in this process
Other
If so, who did the testing?
*
Type NA if does not apply.
Does your child have a 504 Plan or IEP
*
No
Yes
In the process
I need help in this process
Other
My child is struggling in the following academic areas:
*
Reading
Spelling
Handwriting
Writing
Math
Speech & Language
Other
Are you interested in learning more about scholarship options, STOs, and ESAs?
*
Yes
No
Other
Is your child aware of their diagnosis?
*
Yes
No
N/A
Other
Is your child aware of their academic struggles? Compare themselves to others or have anxiety, fear of school, complain of headaches, etc?
*
Yes
No
Maybe
Other
What areas of need would you like to focus on?
*
Testing Options
Current Availability & Remediation
General Questions
Other
Please give as much information as possible here; testing info, journey of discovery, hopes, needs
*
In an ideal scenario, what are you looking for in regards to long term goals for your child?
*
Who referred you to us?
*
If you have testing documents you would like to share, please include that here. These are private files and will not be shared outside of our organization.
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