Tutor Training
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The mission of the Dyslexia Tutoring Program is to teach low-income children and adults with dyslexia or a language-based learning disability to read. This is accomplished through
a professional screening
assessment and
tutoring by volunteers
whom we have
trained in The
Orton-Gillingham
method of reading,
writing, and spelling.

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Intake Form

Student's Name*:
Name of Parent, Guardian or Adult Student*:
Address*:
City, State, Zip*
Date of Birth*:
Name of School*:
Referred By:
Reason for Request:
Household Income*:
Home Phone*:
Cell Phone:
Work Phone:
Number of household members:
Is there a history of learning difficulties in the family?
Yes No
Is this child enrolled in school?
Yes No
Highest grade child has completed?
Has the child repeated a grade?
Yes No
If so, which?
Does the child receive extra help in reading at school?
Yes No
Does the child receive extra help after school?
Yes No
How would you rate your child's...
School Grades
Poor
Fair
Good
Excellent
School Attendance
Poor
Fair
Good
Excellent
Attitude Towards School
Poor
Fair
Good
Excellent
School Conduct
Poor
Fair
Good
Excellent
List any activities/organizations your child is involved in outside of school:
Reading
Is your child experiencing reading difficulty?
Yes
No
Does your child know the letter sounds?
Yes
No
Is your child able to decode?
Yes
No
Does your child reverse letters?
Yes
No
Does your child transpose letters?
Yes
No
Is your child able to blend letter sounds?
Yes
No
Writing, Spelling and Math
Does your child experience problems writing?
Yes
No
Is your child's writing legible?
Yes
No
Does your child reverse letters when writing?
Yes
No
Can your child write in both print and cursive?
Yes
No
Does your child have problems spelling?
Yes
No
Does your child have problems with Math?
Yes
No
Is your child on grade level for Math?
Yes
No
Does your child reverse numbers?
Yes
No
Speech
Does your child have speech problems?
Yes
No
Has your child ever received speech or language services?
Yes
No
Does your child have hearing problems?
Yes
No
Does your child have vision problems?
Yes
No
Which hand does your child prefer to write with?
L R Either
Does your child have problems using his or her hands?
Yes
No
Does your child often fall while running or walking?
Yes
No
Does your child have problems understanding verbal directions?
Yes
No
Does your child have problems with verbal expression?
Yes
No
Health
Does your child have any allergies
Yes
No
If so, explain:
Does your child have asthma
Yes
No
Does your child have migraines?
Yes
No
Has your child been diagnosed with ADD?
Yes
No
Has your child been diagnosed with ADHD?
Yes
No
Are there any medical conditions we should be aware of?
Yes
No
If so, list conditions:
Any problems during pregnancy or childbirth?
Yes
No
Has your child ever had lead poisoning?
Yes
No
Has your child ever had head injuries?
Yes
No
Has your child been diagnosed with emotional problems?
Yes
No
Has your child had any psychological or psychiatric evaluations?
Yes
No
If yes, when and where:
Is the child on any medications?
Yes
No
If yes, list medications:
Does your child receive any other treatment?
Yes
No
If yes, list treatment received:
For Adult Students ONLY
If accepted, do you agree to a background check?
Yes
No
Do you have any prior convictions?
Yes
No

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