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
Welcome — I’m glad you’re here. Please share a few details below so I can better understand your needs and prepare for next steps.
Contact
Preferred contact method
*
Email
Phone
Your full name
*
First Name
Last Name
Child's full name
*
First Name
Last Name
Current or upcoming grade
*
For example: 3rd grade, 7th grade, kindergarten
Areas of Interest
Conditional Follow-Ups
Student date of birth
*
-
Month
-
Day
Year
Date
School name
*
Phone number
*
-
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
Private Education
Other
Email address
*
General Concerns
Best days for an initial call
*
Monday
Tuesday
Wednesday
Thursday
Other
Preferred appointment 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 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?
*
No
Yes
In the process
I need help in this process
Other
Who performed the testing?
*
Type N/A if this does not apply.
Goals
Does your child have a 504 Plan or IEP?
*
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
Are you interested in learning more about scholarship options, STOs, and ESAs?
*
Yes
No
Other
Referral / Upload
Closing
Thank you for taking the time to complete this form. Your responses will help us prepare thoughtfully and follow up as soon as possible.
Is your child aware of their diagnosis?
*
Yes
No
N/A
Other
Is your child aware of their academic struggles?
*
Yes
No
Maybe
Other
Areas of interest
*
Reading
Writing
Math
Executive functioning
Speech
Parent coaching
Private education
Camps
Testing
Not sure
Please share any additional details about testing, your journey, hopes, or needs.
*
What would an ideal long-term outcome look like for your child?
*
If you’re interested in Study Hall Private Education, please share your reasons and goals.
How did you hear about us?
*
Upload any testing documents you’d like to share.
Browse Files
Private files will only be used by our team.
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