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Student History
Information for Inspiring Minds Phone Consultation
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Email
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Your email
Student's First Name
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Your answer
Student's Last Name
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Your answer
Age
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Your answer
Grade
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Your answer
Current School
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Your answer
Your current concerns are:
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Your answer
Is your child on an IEP or 504 plan?
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Yes
No
Other:
Was he/she born full-term?
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Yes
No
If born premature, how early?
Your answer
Has he/she ever received therapies such as PT, OT, Speech Therapy? Please explain:
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Your answer
Please check any warning signs that apply to your child.
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Was/Is slower to learn the alphabet and/or the sounds letters make
Difficulty rhyming
Difficulty memorizing address and phone number
Mixes up sounds within syllables (basghetti-spaghetti, hopsital-hospital, aminal-animal, etc)
Confuses left and right
Letter and/or number reversals
Difficulty sounding out unknown words
Guesses based on pictures, context clues, first letter, shape of the word
Slower to learn to tie shoes
Difficulty getting thoughts out onto paper and/or messy handwriting
Other:
Required
Family History. Does anyone in your family have known dyslexia, or is there anyone who isn't a great speller, doesn't love reading, etc? Please explain:
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Your answer
Parent/Caregiver Name(s)
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Your answer
Phone Number
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Your answer
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