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Intake for Literacy Concerns
ALL INFORMATION PROVIDED WILL REMAIN CONFIDENTIAL.
PLEASE MAKE SURE ALL BOXES HAVE BEEN ENTERED. THANK YOU.
* Indicates required question
Email
*
Record my email address with my response
Child's First Name
Your answer
Child's Last Name
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Your answer
Child's Middle Initial
Your answer
Child's Date of Birth
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MM
/
DD
/
YYYY
Child's Pediatrician
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Your answer
What are your child's hobbies or interests?
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Your answer
What aspect of school does your child enjoy the most?
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Your answer
What are your child's dislikes?
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Your answer
Parent 1: First and Last Name
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Your answer
Parent address
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Your answer
Parent email
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Your answer
Parent phone number
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Your answer
How would you like to be contacted?
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Text
Phone Call
Email
Occupation
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Your answer
Employer
Your answer
Parent 2: First and Last Name
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Your answer
Parent address
Your answer
Parent email
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Your answer
Parent phone number
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Your answer
How would you like to be contacted?
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Text
Email
Phone
Occupation
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Your answer
Employer
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Your answer
Number of child's siblings and age of each.
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Your answer
Has any biological family member ever had a reading disorder, including slow reading?
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Yes
No
Has any biological family member been diagnosed with dyslexia?
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No
Yes
Has your child's hearing been tested or screened in the last year?
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Yes
No
Results of the hearing exam?
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Pass
Fail
N/A
Has your child had their vision tested or screened in the past year?
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Yes
No
Results of vision exam?
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Pass
Fail
N/A
Please list all medications, surgeries, and any other relevant medical information, including birth history.
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Your answer
Were all developmental milestones met on time (talking, walking, playing)?
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Yes
No
Please list all medical diagnosis your child has been diagnosed with.
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Your answer
Does your child
have any allergies?
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Yes
No
Has your child experienced frequent ear infections either in the past or present?
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Yes
No
Does your child attend:
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Public school
Private school
Homeschool
What grade is your child in?
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Your answer
School district name:
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Your answer
School name:
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Your answer
What are your concerns regarding your child's reading and literacy skills?
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Your answer
When did you first become aware of your child's struggles?
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Your answer
Mark all that apply for your child:
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Read for enjoyment
Read very slowly
Actively avoid reading
Prefer to listen to stories/audiobooks rather than read them
Find reading tiring and difficult
Find it hard to read words correctly
Have difficulty finding information in a text
Lose their place when reading
Has difficulty understanding what they have read
Required
Have you made your school aware of your concerns for your child?
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Yes
No
If yes, how did the school respond?
Your answer
Is your child receiving small group reading instruction (also known as MTSS or Tiered Reading)?
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Yes
No
Not sure
Your child's grades are (Check all that apply)
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Mostly A's
Mostly B's
Mostly C's
Not doing well in school
Has anxiety about school/dislikes school
Required
Does your child have an IEP?
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Yes
No
If yes, goals are included in the IEP?
Reading
Speech and/or language
Other
Does your child have an active 504?
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Yes
No
If yes, what accommodations/modifications are included?
Your answer
Has your child ever received help outside of school using a structured literacy approach to reading?
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Yes
No
How did you hear about Speech Ability, LLC?
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Your answer
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