Initial Information 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
Preferred contact method
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Email
Phone
Text
Preferred contact Method
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Email
Phone
Text
Other
Your full name
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First Name
Last Name
Child's full name
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First Name
Last Name
Current or upcoming grade
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For example: 3rd grade, 7th grade, kindergarten
Student date of birth
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-
Month
-
Day
Year
Date
School name
*
Phone number
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-
Area Code
Phone Number
Email address
*
Office that is closest to you:
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Arcadia, Phoenix
Online
Scottsdale
Other
Best days for an initial call
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Monday
Tuesday
Wednesday
Thursday
Other
Preferred appointment times
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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 share them here. We will do our best to offer a time that works well for you.
Has your child received testing or a diagnosis?
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No
Yes
In the process
I need help in this process
Other
If so, who performed the testing?
Type N/A if this does not apply.
Does your child have a 504 Plan or IEP?
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No
Yes
In the process
I need help in this process
Other
What academic areas is your child struggling with?
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Reading
Spelling
Handwriting
Writing
Math
Speech & Language
Other
Areas of Interest
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Speech & Language
Dyslexia Remediation & Support
Parent Coaching
General Homework Help
Mentorship
Handwriting Support
Private Education
Executive Functioning
Camps
Testing
Unknown
Other
Areas of interest
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Reading
Writing
Math
Speech
Parent coaching
Private education
Camps
Testing
Not sure
Are you interested in learning more about scholarship options, proportionate share funds and ESAs?
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Yes
No
Other
Is your child aware of their diagnosis?
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Yes
No
N/A
Other
Is your child aware of their academic struggles?
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Yes
No
Maybe
Other
Please share any additional details about testing, your journey, hopes, or needs.
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What would an ideal long-term outcome look like for your child?
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How did you hear about us?
*
Upload any testing documents you’d like to share.
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