In order to answer your questions to the fullest extent possible, we request that you please provide us with the following information about the student: (*denotes required fields)
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Information regarding the student (check all that apply):
Male
Female
Adult
Child - Age of Child
Reading Difficulties
English Language Learner
Is there a family history of reading difficulties?
Yes
No
Does the individual have or did he/she have any:Early speech and/or language problems?
Yes
No
History of inner ear infections as a child?
Yes
No
Hearing difficulties?
Yes
No
Poor reading and/or spelling skills?
Yes
No
Poor math and/or number skills?
Yes
No
Poor listening skills?
Yes
No
Poor attention and/or concentration?
Yes
No
Known or suspected coordination difficulties?
Yes
No
Known or suspected visual difficulties?
Yes
No
Allergies?
Yes
No
Has the individual had their eyes tested recently?
Yes
No
Has the individual had their hearing tested recently?
Yes
No
Currently enrolled in special education or other remedial programming?
Yes
No
Do you have specific questions or comments ?
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