Parent Solutions - Intake Form & Screener
Dyslexia Advocation, Inc., is an approved 501(3)(C) charity organization that provides support and services for children and adults with dyslexia and other language based learning disabilities.
We collect personal information you provide when you contact us to request support or services. We also collect information from feedback provided by you following the delivery of services. All of the information that we collect is held securely on our Customer Relationship Management (CRM) system and servers.
Dyslexia Advocation, Inc., treats information given to its staff and associates in confidence. We will not normally disclose anything you tell us to any other person or organization, unless you give us permission to share information with a named person or organization. However, it is likely that your information will be shared with colleagues and partners of Dyslexia Advocation, Inc., in order to give you the best possible service and advice, unless you expressly request otherwise.
Student Name: (First Name, Last Name)
Parent Name #1 : (First Name, Last Name)
Parent Name #2 : (First Name, Last Name)
Parent # 1 Mobile Number (SMS)
Parent # 2 Mobile Number (SMS)
Parent # 1 Email
Parent # 2 Email
Address: (Street, City, Zip)
State of Residence
DISTRICT OF COLUMBIA
NORTHERN MARIANA IS
Student Date of Birth
Hispanic or Latino
Black or African American
Native Hawaiian or Pacific Islander
Asian (Not Hispanic or Latino)
Native American or Alaska Native (Not Hispanic or Latino)
Two or more races (Not Hispanic or Latino)
Student School Name
Reason for Request
Suspect Dyslexia or other SLD
Independent Education Program, IEP
Related Services (OT, Speech, Social Work, etc.)
Number of Household Members
Total Household Income
$46,000 - $70,000
$71,000 - $95,000
$96,000 - $120,000
$121,000 - $145,000
$146,000 - $170,000
$171,000 - $195,999
Has your child had any psychological or psychiatric evaluations?
Does your child have an Individualized Education Program (IEP)?
If your child has an IEP, what is their primary diagnosis
Specific Learning Disability, SLD (dyslexia, dysgraphia, dyscalculia, auditory processing disorder, nonverbal learning disorder)
Other Health Impairment, OHI (ADHD (inattentive, hyperactivity, combined)
Autism Spectrum Disorder (ASD)
Emotional Disturbance (generalized anxiety, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), social phobia (social anxiety disorder)
ADHD (inattentive, hyperactivity, or combined)
Speech or Language Impairment
Visual Impairment, including Blindness
Traumatic Brain Injury
Does your child receive extra help in reading in school
Does you child receive extra help in reading after school
How did you find us?
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This form was created inside of Dyslexia Advocation.