1:1 Reading Intervention Application

Parent/Guardian Information

Parent Name *

Phone *

Email *

State *

Student Information

Student Name *

Date of birth *

School Grade *

Has your child been diagnosed with dyslexia or a reading difficulty? *

Reading Concerns

What concerns brought you here?

What are some of your childs' strengths?

School Support

Has your child received reading intervention before? *

Does your child currently have:

IEP

504 Plan

RTI/MTSS

None

Scheduling

Preferred Format: *

Parent Goals

What are your top goals for your child over the next 6-12 months? Please provide any additional information here. *

Pricing and Policy Agreement

I acknowledge the rate is $80 per 50 minute session, due 48 hours prior to session start time. *

Yes, I agree.

I understand the cancellation policy: Cancellations require 24 hours notice. Full payment will be due for late cancellations or no-shows. *

Yes, I agree.

I acknowledge that a package of instructional materials will be mailed to my home for use during tutoring sessions. If any item is lost or damaged, replacements can be requested at a rate of $25 per material, or families may choose to replace the item independently. *

Yes, I agree.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Signature *

Clear