Admissions

Admissions

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Admissions Inquiry

*Required

*Parent: E-mail:
*Home Phone: Alt. Phone:
*Address:
*City: *State:    *Zip:
*Student: *Age:    *D.O.B:
*School: *Grade:
Referred by:
 
 
Diagnoses:
Dyslexia   APD   Dyscalculia   ADHD  
NVLD   Dysgraphia   Sensory Integration Disorder
Other


Symptoms/Difficulties with:

Language/Reading
Reading Fluency
Word Attack
Comprehension
Spelling

Math
Math Computation
Math Facts
Word Problems

Social
Independence
Confidence
Sportsmanship
Friendships
Nonverbal cues
Changes in routine

Organization
Time/Sequencing
Decision making
Completing tasks

Attention
Focusing/Distractibility
Following directions
Impulsivity

Motor Skills
Handwriting
Coordination

Memory
Studying/Test taking
Recall of facts


Desired results/Improvements:

Reading
Math
Writing composition
Handwriting
Social Skills
Attention

Study Skills
Organization
Self Advocacy
Independence
Confidence
Other


Miscellaneous: