The Literacy Coach Reading and Writing Center First Visit Questionnaire
Welcome to The Literacy Coach Reading and Writing Center! We are here to engage you in meaningful dialogue about reading and writing development and enrichment. Through our host of informed and accessible professional educators, we are able to offer reading and writing intervention supports, small group classes for all ages, and enrichment creative activities. Our hope is that you will explore and participate in a variety of activities for years to come!
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Email *
Primary Contact Person (ex. mom, dad, grandparent, guardian) and Cell Phone
Mom
Secondary Contact's Name & Phone
Name of Student *
Primary Home Address *
Grade/School (if applicable) *
Date of Birth *
MM
/
DD
/
YYYY
Please describe the challenges your child has faced in reading and writing and/OR share your child's interests in reading and writing. *
For which program(s) would you like to enroll? *
Required
Student's Cell Phone (if applicable) *
Does your child currently receive literacy support at school? If so, what does that support look like? (ex. 30 min daily with Title 1 teacher for comprehension, or twice weekly with the Reading Specialist for phonics) *
Does your child have a diagnosis for any of the following: *
Does your reader/writer have an IEP or 504 in place? *
Approximate date of last vision screening?
Clear selection
Does you child wear glasses? *
Does your child have visual tracking issues? *
With which hand does your child prefer to write? *
I would give permission for correspondence with the classroom teacher and specialists at my child's school. *
Approximate date of last hearing screening?
Clear selection
Would you like to receive text reminders about appointments?
Clear selection
A copy of your responses will be emailed to the address you provided.
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