Adult Intake and Screening DTP’s tutoring program is designed specifically for people with a dyslexic learning style.There are many reasons why you might have trouble reading. Our application process helps us determine if DTP can help you with your reading difficulties. Once we receive your Intake, we’ll email you a list of documents needed to verify your financial eligibility and evaluate you for services. You have 4 weeks from the date of that email to submit these documents to DTP. You must submit all requested documentation by the specified deadline to be considered for services. Completing this Intake is the first step in applying for services. You must complete all fields on this form.GENERAL INFORMATIONName(Required) First Last Email(Required) Student Date of Birth(Required) MM slash DD slash YYYY 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 Please provide at least one phone number below:(Required) Cell Phone Home Phone Work Phone Cell Phone(Required)Home Phone(Required)Work Phone(Required)Would you like to receive text messages regarding the status of your application? Yes, I would like to receive text messages regarding the status of my application. By selecting yes, you agree to receive text messages from Dyslexia Tutoring Program related to tutoring services. Message & data rates may apply. Message frequency varies. Reply HELP for help and STOP to cancel.Relationship to the applicant/student:(Required)Select OneSelfParent/GuardianFamily Member/RelativeSocial WorkerOtherPlease specify your relationship to the applicant/student.(Required)Referred By:(Required)Select OneSchool/TeacherCommunity ProgramEventSocial MediaSearch EnginePlace of WorshipPlease provide referral details.Tell Us Why You Are Seeking Help(Required)Annual Household Income(Required)Note: We require documentation (e.g., most recent income tax return/Form 1040; most recent paystub; government benefits award letter) to verify your income and financial eligibility for our free services.Number of Household Members(Required)Highest Grade Completed(Required)Race(Required)WhiteBlack/African AmericanHispanic or LatinoAmerican IndianAlaska NativeAsianPacific IslanderNative HawaiianArab/Middle EasternSome Other RaceMultiracialPrefer Not to AnswerGender(Required)MaleFemaleNon-gender/BinaryPrefer Not to AnswerIn case of emergency (ICE), please contact: Primary Contact Name(Required) First Last Primary Contact Phone(Required)Secondary Contact Name First Last Secondary Contact PhoneINTAKE - GENERALHave you ever been diagnosed with a learning disability?(Required) Yes No Is there a history of learning disabilities in your family?(Required) Yes No I Don’t Know Have you had any educational evaluations?(Required) Yes No If yes: you will need to provide copies of these evaluations to be considered for services.Have you had any psychological or psychiatric evaluations?(Required) Yes No If yes: you will need to provide copies of these evaluations to be considered for services.INTAKE - READINGAre you experiencing reading difficulty?(Required) Yes No Do you know letter sounds?(Required) Yes No Are you able to sound out (decode) words?(Required) Yes No Do you reverse letters when reading? For example, do you see a “b” instead of a “d” in words when reading?(Required) Yes No Do you switch the position (transpose) of letters within words when reading? For example, do you see, “taepot” instead of “teapot?”(Required) Yes No Are you able to blend letter sounds? For example, can you blend “b” and “l” as in b̲l̲ack, b̲l̲ue, b̲l̲oom?(Required) Yes No INTAKE - WRITING & SPELLINGDo you experience problems writing?(Required) Yes No Is your writing legible?(Required) Yes No Somewhat Do you reverse letters when writing?(Required) Yes No Do you have problems spelling?(Required) Yes No Can you write in:(Required) Print Cursive Both Neither INTAKE - SPEECH, HEARING & VISIONDo you have speech problems?(Required) Yes No Have you ever received speech or language services?(Required) Yes No Do you have hearing problems?(Required) Yes No Do you have vision problems?(Required) Yes No INTAKE - HEALTHDo you have any allergies?(Required) Yes No Have you been diagnosed with ADHD?(Required) Yes No Do you have any medical conditions we should be aware of?(Required) Yes No If so, please explain:(Required)Have you ever had lead poisoning?(Required) Yes No Are you currently taking any medications?(Required) Yes No If yes, please list:(Required)INTAKE - CONSENT & DISCLOSURESDo you have any prior convictions?(Required) Yes No Do you consent to a background check?(Required) Yes No This field is hidden when viewing the formHave you had a recent psychological assessment within the last two years?(Required) Yes No This field is hidden when viewing the formIf yes, when and where(Required)This field is hidden when viewing the formHave you had a recent educational assessment within the last two years?(Required) Yes No This field is hidden when viewing the formIf yes, when and where(Required)CAPTCHA
