* 1. Mother's First and Last Name

* 2. Father's First and Last Name

* 3. Please provide 2 phone numbers and indicate whether cell or land line.

* 4. Email address

* 5. Child's Name

* 6. Child's Age and Grade

* 7. Child's School

* 8. Referred by:

* 9. Geographic area of home residence:

* 10. Psychoeducational testing by whom?

* 11. What is your perception of your child’s learning needs?

* 12. Describe briefly any roadblock in your child’s development (language, motor, social and emotional skills):

* 13. Your analysis of your child’s likes, dislikes, hobbies, leisure activities, behavioral and social traits:

* 14. Relevant school history (areas of strength and weakness):

* 15. Other services your child currently receives, for example, counseling, vision therapy, tutoring:

* 16. Other services your child has received in the past, for example, counseling, vision therapy, tutoring:

* 17. Physical/mental health, including recurring illnesses or conditions such as asthma, ear infections, concussions or speech problems:

* 18. Languages other than English spoken in family:


It is of tremendous value to you to view the videos that describe my unique approach to educating students with complicated learning needs. Our discussion will be much more productive if you have a solid overview of my effective system.

If you haven't seen the videos on my website explaining my educational therapy approach, please view them before answering the questions that follow. Here is the link to the first video.

In the space below, please describe which of the five problems I discussed in the video you believe your child is struggling with, 1) different learning style, 2) gaps in knowledge, 3) weak learning skills, 4) poor academic management, 5) learned helplessness.

* 20. Please describe the goals you have for your child after high school. Be specific. Do you want your child to go to college?

* 21. Please list your goals and expectations for educational therapy:

* 22. On a scale of 1 - 10, how ready and willing are you to facilitate your child's educational improvement.

* 23. On a scale of 1-10, how eager for help is your child? Do you believe your child will have a positive response to educational intervention?

* 24. Questions about business issues such as costs, scheduling, etc.