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Personal Information:
First Name:
Last Name:
School and Grade (if applicable):
Telephone Number:
FAX:
E-mail:
Street Address:
City:
Province/State:
Country:
Postal/ZIP Code:
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- Please tell us how you located us:
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- Area of Interest:
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- Comments:
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General Questionnaire:
1. Do you feel your child is underachieving in school?
yes no
2. Does your child feel he or she is "stupid"?
yes no
3. Is your child having reading, spelling and/or language difficulties?
yes no
4. Is your child having a problem remembering math facts no matter
how many times he reviews them? i.e. multiplication tables.
yes no
5. Does your child have difficulty listening, remembering or concentrating?
yes no
6. Is your child disorganized?
yes no
7. Has there been a change in attitude toward school or has your
child recently exhibited negative behaviours either in school
or at home?
yes no
Reading Questionnaire:
1. Does your child make wild guesses when reading unknown words?
yes no
2. Does your child substitute similar words that start with the
same letter?
(reads "stop" instead of "step" or "money" instead of "monkey")
yes no
3. Does your child shuffle the order of letters inside words?
(reads "bulb" instead of "blub" or "prat" instead of "part")
yes no
4. Does your child substitute words that have similar meanings?
(reads "house" instead of "home" or "long" instead of "length")
yes no
5. Does your child shorten long words into shorter ones?
(reads "elope" instead of "envelope" or "computer" instead of
"contemporary")
yes no
6. Does your child say the first sound in a word and then "stick"?
(says "rr-" and then stops when trying to read "radish")
yes no
7.Does your child say the name of the first letter of a word instead
of its sound?
(says "kay-" when looking at the word "kite" or reads "cake" instead
of "kite")
yes no
8. Does your child make letter and/or number reversals?
(says "76" when looking at "67")
yes no
9. Does your child confuse "b" and "d" only?
yes no
10. Does your child write his or her name mirror-reversed or starting
at the end?
(writes the name "Carol" starting with the "I")
yes no
11. Does your child try to "sound out" sight-words using phonic
rules?
(reads "lowg" for "laugh" or reads "chronic" with a "ch-" sound,
not a "k-")
yes no
12. Does your child reverse the letter-sequence of whole words?
(reads "was" instead of "saw" or "gib" instead of "big")
yes no
13. Does your child have trouble remembering new words?
(learns a new word on the first line of a paragraph but forgets
it before the last line of the same paragraph)
yes no
14. Does your child hold a book upside down without noticing?
yes no
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