Dyslexia Screening Intake Form
Client Date of Birth
Name of Person Completing Intake Form
Please list any medical, school, or other diagnoses:
Please list any current medications:
Please provide the date of your child's most recent vision exam or screening:
Vision exam or screening results:
Is there a history of dyslexia or other reading, spelling, and/or written expression difficulties in the family?
Has your child ever received a dyslexia evaluation? If so, please describe the outcome and bring copies of any written reports.
Has your child previously received any dyslexia services at another facility or school?
Does your child currently receive any outpatient therapy services?
Speech Language Therapy
Has your child previously received any therapy or tutoring services? Please describe below.
Current Grade Level
Has your child ever been retained and repeated a grade?
As of 2019 the Indiana Department of Education requires all K-2 students to be screened for signs of dyslexia. To your knowledge, has your child been given a universal dyslexia screener at his/her school?
If "Yes" please state if your child was identified (at risk/at some risk) and received any additional screenings (Level I/Level II). Please email or bring any written documentation provided by the school to your screening.
Does your child have a 504 Plan or Individualized Education Program (IEP)? If so, please describe any services or accommodations your child receives and/or provide a copy to K1ds Count.
Should be Empty: