Parent Name
email
Phone
*
Childs Name
*
Grade
Pre-K(ages 2-5)
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
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Format (In-person / Online / Either)
Schedule preference
Service interested in (Tutoring / Small Group / Not sure)
Payment preference (Pay per session / Monthly / Not sure)
Pay per session
Monthly
Not sure
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Reading support needs(check all that apply)
Learning letter names
Learning letter sounds (phonics)
Blending sounds to read words
Sounding out unfamiliar words
Sight words / high-frequency words
Reading fluency (reading smoothly and accurately)
Reading comprehension (understanding what is read)
Spelling / writing words
Writing support
Building confidence / motivation
Focus/attention during reading time
Suspected dyslexia or other reading difficulty
I am not sure. I would like to schedule a consultation.
Reading concerns/goals
Has had reading support before?
Yes
No
Has a current IEP or 504?
IEP
504
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