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.
* Required
Student Name: (First Name, Last Name)
*
Your answer
Parent Name #1 : (First Name, Last Name)
*
Your answer
Parent Name #2 : (First Name, Last Name)
*
Your answer
Parent # 1 Mobile Number (SMS)
*
Your answer
Parent # 2 Mobile Number (SMS)
*
Your answer
Parent # 1 Email
*
Your answer
Parent # 2 Email
*
Your answer
Address: (Street, City, Zip)
*
Your answer
State of Residence
*
Choose
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NORTH DAKOTA
NORTHERN MARIANA IS
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
VIRGIN ISLANDS
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Student Date of Birth
*
MM
/
DD
/
YYYY
Student Age
*
Your answer
Student Gender
*
Choose
Male
Female
Gender diverse
Non-binary/non-conforming
Student Race/Ethnicity
*
Choose
Hispanic or Latino
White
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
*
Your answer
Student Grade
*
Your answer
Reason for Request
*
Choose
Suspect Dyslexia or other SLD
Independent Education Program, IEP
Advocacy
Tutoring
Screening/Evaluation
Related Services (OT, Speech, Social Work, etc.)
Other
Number of Household Members
*
1
2
3
4
5
6
Other:
Required
Total Household Income
*
Choose
< $45,000
$46,000 - $70,000
$71,000 - $95,000
$96,000 - $120,000
$121,000 - $145,000
$146,000 - $170,000
$171,000 - $195,999
> $196,000
Has your child had any psychological or psychiatric evaluations?
*
Yes
No
Does your child have an Individualized Education Program (IEP)?
*
Yes
No
If your child has an IEP, what is their primary diagnosis
*
Choose
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
Deafness
Hearing Impairment
Deaf-Blindness
Orthopedic Impairment
Intellectual Disability
Traumatic Brain Injury
Multiple Disabilities
N/A
Does your child receive extra help in reading in school
*
Yes
No
Does you child receive extra help in reading after school
*
Yes
No
How did you find us?
*
LinkedIn
Facebook
Instagram
Pinterest
Website
Other:
Submit
Never submit passwords through Google Forms.
This form was created inside of Dyslexia Advocation.
Report Abuse
Forms
