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Connect ~ 2 ~ Learning LLC
Student Record Form - "Get to Know Me"
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* After this form is submitted, you will be contacted for setting up a date/time for an INITIAL ASSESSMENT.  The cost of the assessment is $50 and generally takes about an hour to administer. Afterwards the results are discussed with the guardian of student (or student if age 18 or over) , along with our program recommendations. 
PARENT NAME (IF UNDER 18)
CONTACT NUMBER
ANY OTHER CONTACT INFO (NAMES, NUMBERS/EMAILS) YOU WOULD LIKE TO SHARE?
*Example - more than one parent, grandparent, etc..
STUDENT NAME
ADDRESS
STUDENT DATE OF BIRTH
STUDENT SCHOOL GRADE FOR
 CURRENT SCHOOL YEAR. *If school recently ended, list the upcoming school year grade.
WHERE DOES STUDENT ATTEND SCHOOL?
WHO IS THE STUDENT'S PRIMARY TEACHER?
STUDENT RETENTION? ( Check all that applies)
STUDENT MEDICAL HISTORY AND OTHER PERTINENT INFORMATION (Check all that applies)
FOR ANY AREA ABOVE MARKED WITH A STAR,  PLEASE SHARE MORE SPECIFIC INFORMATION. FOR EXAMPLE, IF YOUR CHILD HAS MEDICAL CONCERNS - PLEASE DESCRIBE. IF THE STUDENT HAS HAD A SURGERY, WHAT TYPE? IF THERE IS A FAMILY HISTORY OF DYLSEXIA, WHAT RELATION TO THE STUDENT?  IF YOUR CHILD HAS BEEN DIAGNOSED WITH A CONDITION NOT SPECIFIED ABOVE, NAME THE CONDITION.  
HOW IS THE STUDENT MOTIVATED ? (check all that applies)
LIST STUDENT INTERESTS AND/OR HOBBIES
LIST STUDENT'S STRENGTHS
LIST STUDENT'S WEAKNESSES
FEEL FREE TO ADD ANY OTHER INFORMATON NOT PREVIOUSLY MENTIONED TO HELP IN GETTING TO KNOW THE STUDENT. 
How did you learn about the Dyslexia Center?
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TODAY'S DATE


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