intake - Coal Creek Tutoring

Intake Information

Please help me get to know your child and family better by answering the following questions.

Child's name:

Child's date of birth:

School and grade level:

Parent/Guardian names:

Home address:

Phone number:

Parent email:

Student's first language:

Other languages spoken in the home:

Please list/describe child's strengths, interests, sports, hobbies:

Please list/describe child's challenges, struggles, areas working on:

Has your child had a diagnostic evaluation? If so, are you willing to share a copy of the findings?

Have you had any other intervention/treatment for dyslexia? If so, program name and dates?

Does your child have an IEP or 504 in place at school? Is it working/being followed?

How can I best support your child and family?

Anything else you'd like me to be aware of?