First Name

Last Name

E-mail

Address

City

State

Zip Code

Country

Phone (landline)

Phone (cell)

Interested for a child or an adult? Interested for a child or an adult? For a child For an adult

Child's Name

Child's Age Child's Age 6-8 years 9-12 years 13-17 years

Adult's Name

Adult's Age Adult's Age 18-30 years 30 years and above

School School Homeschool Public IEP or 504 Private Attending or has attended college

Reading Reading Inaccurate reading and spelling Low comprehension Low word recognition Struggling to maintain self-esteem Desires and will accept help

Attention/Behavioral Decisions Attention/Behavioral Decisions Loses focus frequently, lacks control Lacks understanding of consequences Poor behavioral choices Struggling to maintain self-esteem Desires and will accept help

Math Math Struggles with story problems Struggles with numeric processes Counts with fingers Struggles with math facts Struggling to maintain self-esteem Desires and will accept help

Life concepts resulting in difficulties Life concepts resulting in difficulties Verbal communication Non-verbal or low verbal communication Sensory processing difficulties Struggles socially Struggles with how to function in the world Had or is receiving interventions Problems dealing with others Poor behavioral choices Struggling to maintain self-esteem Desires and will accept help Other - Please name

Please name other concerns

Prefered Contact Method Prefered Contact Method Phone Email No preference

Best contact day Best contact day Weekday Saturday No preference

Best time of day Best time of day Afternoon Evening No preference

Desired Program Location Desired Program Location Prefer to come to Springfield Prefer Susan to travel to my location Undecided

Your Message to Susan

I agree to the Terms of Service I agree to the Terms of Service I agree to the Terms of Service