Please complete this form to request a free initial consultation. I will attempt to contact you within 24 hours of receipt Monday through Friday.
Your Name (First and Last)
Your Child's Name (First and Last).
If this is a self-referral, please write "self."
Your phone number
In what town/city do you live?
How did you find GBW Educational Services?
International Dyslexia Association
Boulder Psychotherapist Institute Directory
What is your role in this consultation request?
Self-referral (I am an adult seeking consultation for myself)
Self-referral (I am a minor age 11 - 17 seeking consultation for myself)
What school district and/or school do you current attend OR Of what school district are you a representative?
Please write "N/A" if this is not a request related to educational testing or you are an adult seeking evaluation for possible workplace accommodations.
What type of school do you/does your child currently attend?
My child's home school in the public school district - the neighborhood school near my house that I did not have to open enroll into
Adult 18+ not in school
A public school within the public school district we reside that I open enrolled into
College (ages 18 to 21)
Preschool/Early Childhood Center/Daycare
N/A (only if this request is not for an evaluation)
How old is your child OR What is your age (if self-referring)?
Birth to under 3 years old
Preschool (3 to 5 years old)
Elementary (Kindergarten to 5th grade)
Middle School (6th to 8th grade)
High School (9th to 12th grade)
Currently in college (undergraduate)
Currently in graduate school
Adult (18+ not currently in school)
N/A (only if this request is not in reference to an evaluation or educational consultation)
What is the best time to contact you?
I typically contact families between 4 and 7pm due to full time commitments. If you require a call during the hours of 8am to 4pm, I will do my best to accommodate you. Please mark all that apply.
Mon - Fri 7:00am - 8:00am
Mon - Fri 8:00am - 11:00am
Mon - Fri 11:00am-2:00pm
Mon - Fri 2:00pm - 4:00pm
Mon - Fri 4:00pm - 7:00pm
Mon - Fri 7:00pm - 8:00pm
Sat 10:00am - 2:00pm
What is your request for consultation related to?
Please mark all that apply.
Special Education Evaluation
Special Education Process Consultation
Early Access Consultation
Gifted Process Consultation
Diagnostic/Psychoeducational Assessment (cognitive, academic, social-emotional, developmental, etc. or to determine ADHD, Dyslexia, Autism, or other diagnoses)
Autism Assessment or Consultation
Please provide any relevant information to allow Georginia to customize your consultation. Please be as detailed as possible to allow for Georginia to plan your consultation appropriately.
Send me a copy of my responses.
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