Clinical Services Intake Information

To register for diagnostic testing or tutoring, please complete the form below.

Parent/Guardian Information
All fields marked with * are mandatory.

Personal Details
Last name:*		First name:*
Mailing Information
Mailing Address:*		City:*
State:*		Zip:*
Contact Details
Home Phone Number:*	( )	Work Phone Number:*	( )
E-mail address:

Student Information

Personal Details
Last Name:*		First Name:*
Date of Birth (mm/dd/yy):*		Age:*
Grade:*
School:*

Referring Individual*

How did you hear about the Reading Center?
Brochure
School personnel/Teacher
Friend
Website
Other

Provide a brief history of the student's reading and writing development and any of the problems he/she has encountered.

Type of Service Desired*

Testing

Tutoring

Both

 

If you are interested in tutoring services, check the preferred semester and time*

Fall: Tuesday, 4:30-6 p.m.

Winter: Tuesday, 4:30-6 p.m.

Summer: Monday, Tuesday, Wednesday, Thursday July 7-31, 10-12