18 and Under Intake

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 child's reading difficulties.

Once we receive your Intake, we’ll email you a list of documents needed to verify your financial eligibility and evaluate you child 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 INFORMATION

Student Name(Required)

First Last

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

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)

Please specify your relationship to the applicant/student.(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

In case of emergency, please contact:(Required)

Parent/Guardian listed above.

Would you like to submit a secondary contact?

Yes, I would like to submit a secondary contact.

Secondary Contact Name

First Last

Secondary Contact Phone

Student Date of Birth(Required)

Student Gender(Required)

Student Race/Ethnicity(Required)

Is this child enrolled in school?(Required)

Yes

Student School District (County)(Required)

Student School Name(Required)

Is your child's school not listed above?

Yes, it is not listed from the above option.

Please enter the name of your child's school.(Required)

Child's Current Grade(Required)

School Type(Required)

Referred By(Required)

Tell us why you are seeking help for your child(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.

INTAKE - GENERAL

Number of Household Members(Required)

Has your child ever been diagnosed with a learning disability?(Required)

Yes

Is there a history of learning difficulties in the family?(Required)

Yes

Don't Know

Has the child repeated a grade?(Required)

Yes

If yes, which grade?(Required)

Has your child had any educational evaluations?(Required)

Yes

If yes: you will need to provide copies of these evaluations to be considered for services.

Does the child receive extra help in reading at school?(Required)

Yes

Does the child receive extra help after school? *(Required)

Yes

How Would You Rate Your Child's...

School Grades(Required)

Excellent

Good

Fair

Poor

School Attendance(Required)

Excellent

Good

Fair

Poor

School Attitude(Required)

Excellent

Good

Fair

Poor

School Conduct(Required)

Excellent

Good

Fair

Poor

Note: You will need to provide copies of recent report cards, a teacher referral from your child’s school, and a copy of your child’s IEP if they have one, along with copies of any educational testing to complete your application.

INTAKE - Reading

Is your child experiencing reading difficulty?(Required)

Yes

Does your child know their letter sounds?(Required)

Yes

Is your child able to sound out (decode) words?(Required)

Yes

Does your child reverse letters when reading? For example, do they see a “b” instead of a “d” in words when reading?(Required)

Yes

Does your child switch the position (transpose) of letters within words when reading? For example, do they see, “taepot” instead of “teapot?”(Required)

Yes

Are your child able to blend letter sounds? For example, can they blend “b” and “l” as in b̲l̲ack, b̲l̲ue, b̲l̲oom?(Required)

Yes

INTAKE - Writing and Spelling

Does your child experience problems writing?(Required)

Yes

Is your child's writing legible?(Required)

Yes

Does your child reverse letters when writing?(Required)

Yes

Can your child write in:(Required)

Cursive

Both

Neither

Does your child have problems spelling?(Required)

Yes

INTAKE - Speech, Hearing & Vision

Does your child have speech problems?(Required)

Yes

Has your child ever received speech or language services?(Required)

Yes

Does your child have hearing problems?(Required)

Yes

Does your child have vision problems?(Required)

Yes

INTAKE - Health

Does your child have any allergies?(Required)

Yes

If yes, please list allergies(Required)

Has your child been diagnosed with ADD or ADHD?(Required)

Yes

Are there any medical conditions we should be aware of?(Required)

Yes

If so, please explain(Required)

Has your child had any psychological or psychiatric evaluations?(Required)

Yes

If yes: you will need to provide copies of these evaluations to be considered for services.(Required)

Has your child ever had lead poisoning?(Required)

Yes

Is the child on any medications?(Required)

Yes

If yes, please list medications(Required)