Parent or Guardian's Name *

First Name

Last Name

Phone Number *

(###)

###

####

My child needs help with: *

Reading and Writing (Orton-Gillingham Approach)

Math and Executive Functioning (Math Curriculum and Feuerstein's Instrumental Enrichment)

Behaviour Intervention & Social Skills (Autism Social Skills Summer Camp Using Minecraft)

Student's Current School Level: *

Primary (Grades 1-7)

Secondary (Grades 8-12)

My child is currently attending:

Home School

Private School

Public School

Has your child been evaluated (or is currently being evaluated) for special education services? *

Yes, they have been evaluated.

Yes, they are currently being evaluated.

No, they have never been evaluated.

Has your child ever been offered special education services by your school? *

Yes.

No.

I don't know.

Has your child’s school determined eligibility for special education services within the last two years? *

Yes.

No.

I don't know.

Does your child receive special education under an Individualized Education Plan (IEP)? *

Yes.

No.

I don't know.

Does your child have a formal diagnosis? *

Yes.

No.

Teacher's Name

First Name

Last Name