18 and Under Intake and Screening Student Name(Required) First Last Parent Name(Required) First Last Parent Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Date of Birth MM slash DD slash YYYY Student School Name(Required)Referred By(Required)Reason for Request(Required)Home PhoneCell PhoneWork PhoneAnnual Household Income(Required)Number of Household MembersIs there a history of learning difficulties in the family? Yes No Is this child enrolled in school? Yes No Child's Current GradeHas the child repeated a grade? Yes No If yes, which grade?Does the child receive extra help in reading at school? Yes No How Would You Rate Your Child's...School Grades Good Fair Poor School Attendance Good Fair Poor School Attitude Good Fair Poor School Conduct Good Fair Poor ReadingIs your child experiencing reading difficulty? Yes No Does your child know their letter sounds? Yes No Is your child able to decode? Yes No Does your child reverse letters when reading? Yes No Does your child transpose letters when reading? Yes No Is your child able to blend letter sounds? Yes No Writing and SpellingDoes your child experience problems writing? Yes No Is your child's writing legible? Yes No Does your child have problems spelling? Yes No Can your child write in both print and cursive? Yes No SpeechDoes 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? Left Right Either HealthDoes your child have any allergies? Yes No If yes, please list allergiesHas your child been diagnosed with ADD or ADHD? Yes No Are there any medical conditions we should be aware of? Yes No If yes, please list medical conditionsHas your child had any psychological or psychiatric evaluations? Yes No If yes, when and whereHas your child ever had lead poisoning? Yes No Is the child on any medications? Yes No If yes, please list medicationsCAPTCHA 67139
