Reading Checklist

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Reading Checklist

Before we can add your child to our waiting list, you will need to fill out this form. Please answer each question below.

Email *

Phone number *

Child's Name: *

Parent/Guardian Name: *

Child's Date of Birth: *

YYYY

Child's Grade: *

Child's School *

Public

Homeschool

Private

Charter

Has your child been tested for dyslexia? *

Yes, and has been officially diagnosed with dyslexia.

Yes, and did not get diagnosed with dyslexia. However, I think my child has dyslexia.

No, but I think my child has dyslexia.

I've not been interested in getting my child tested.

Is your child well-behaved?

Yes

For the most part

Sometimes

Clear selection

How did you hear about Therapy 4 Kids?

Internet search

Friend

Doctor

School or co-op

Another professional (counselor, music teacher, service coordinator etc...)

Sign on building

Social Media (Facebook, Instagram etc...)

Clear selection

Clear form

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