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 *
Student Date of Birth *
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Student Age *
Student Gender *
Student Race/Ethnicity *
Student School Name *
Student Grade *
Reason for Request *
Number of Household Members *
Required
Total Household Income *
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 *
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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