Reading Intervention Form

To sign up for any Reading Tutoring/Intervention sessions with Lindsay Munroe, Reg. Educator - Reading Specialist, please fill out the form below.

If a question does not apply to the clients current situation please say NA.

Please select the Reading Tutoring/Intervention Service you would like to register for:

Direct 1:1 Reading Intervention
K-1 - "Early Literacy Explorers" Group - **Summer only**
Grades 1-2 - "Reading Boosters" Group - **Summer only**
Grades 3-4 - "Literacy Leaders" Group - **Summer only**
Grades 5-6 - "Reading Scholars" Group - **Summer only**

Client's Name *

First

Last

Is the person registering a new client? *

Yes
No

Client's Date of Birth (Month/Day/Year) *

Client's Gender *

Male
Female
Other

Preferred Pronouns *

She/Her
He/Him
Other

Preferred Pronouns (Please specify): *

Primary Caregiver's Name *

First

Last

Relationship to the client? (i.e. Parent, Grandparent, Social/Support Worker, etc.) *

Secondary Caregiver's Name

First

Last

Relationship to the client? (i.e. Parent, Grandparent, Social/Support Worker, etc.) *

Primary Email Address *

Secondary Email Address

Primary Phone *

Secondary Phone

Would you like to update the client's address? *

Yes
No

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

CLIENT INFORMATION

Client's Family Relationship *

Nuclear Family (Two parents raising 1+ children in the home)
Single Parent Family (One parent raising 1+ children on their own)
Blended Family (Combination of parents or children from previous relationships)
Grandparent Family (One or more grandparent raising 1+ children in the home)
Extended Family (Several generations of family living in the same home)
Other, please specify.

If other, please specify the family dynamic. *

Does the client have any siblings? *

Yes
No

Please list the children's names, ages and genders (i.e. Name, Age, Gender) *

Client's first language: *

Other languages spoken in the home:

EDUCATION

Is the client currently attending school? *

Yes
No

Please indicate the school name, and the client's current grade: *

Please indicate the teacher's name: *

Has the client received services at school? *

Yes
No

Please indicate which services the client may have received at school: *

Please indicate the service(s) provided if not listed above: *

MEDICAL HISTORY

Has the client had any of the following health concerns: *

Select all that apply

Please indicate the client's allergies: *

Please indicate any serious illness: *

Please indicate any serious injury: *

Please identify other health concerns not listed above: *

Has the client been seen by/referred to any of the following specialists: *

Please choose all that apply.

Please indicate the reason for visit/referral to the above specialist(s): *

Physician and/or other Healthcare Professional(s) who have seen the client (Please include the year seen):

Doctor, Speech-Language Pathologist, Occupational Therapist, Physical Therapist, Dentist, Orthodontist, Registered Nurse, etc.

Does the client have any formal diagnoses (i.e. by a Family Doctor, Specialist, Therapist, etc,) *

Speech and/or Language Delay/Disorder
Autism Spectrum Disorder (ASD)
Global Development Delay (GDD)
Attention-Deficit Hyperactivity Disorder (ADHD)
Attention-Deficit Disorder (ADD)
Other, please specify below.
No Formal Diagnosis.

Please list the year the client was diagnosed, where the diagnosis is from and if you have reports? *

Has the client been hospitalized in the last 5 years? *

Yes
No

Please indicate the reason the client was hospitalized and when. *

Has the client undergone any surgeries in the past? *

Yes
No

Please indicate the type of surgery and the year it occurred: *

Does the client currently take any medications? *

Yes
No

Please indicate current medications: *

Has the client had their hearing tested? *

Yes
No

When was the hearing tested and what were the results? *

Has the client had their vision tested? *

Yes
No

When was the vision tested and what were the results of the vision test? *

Does the client wear glasses or hearing aids? *

Glasses
Hearing Aids
Glasses & Hearing Aids
None of the Above

Does the client use adaptive equipment or mobility aids? *

Yes
No

i.e. walker, wheelchair, AFO's, adaptive utensils, etc.

Select the adaptive equipment or mobility aid(s) used by the client:

AFO (Ankle Foot Orthosis)
Wheelchair
Other

Please indicate other adaptive equipment or mobility aids not listed above: *

SPEECH, LANGUAGE & OCCUPATIONAL CONCERNS

SPEECH / VOICE: Difficulties with: *

LANGUAGE / COMMUNICATION: Difficulties with: *

Interaction and Engagement
Using Expressive Language
Understanding Language (receptive language skills, basic concepts, directions, etc.)
None of the Above

SOCIAL LANGUAGE: Difficulties with: *

OCCUPATIONS: Difficulties with: *

Has the client ever had Speech Language Therapy , Occupational Therapy or Reading Intervention before? *

Speech Language Therapy
Occupational Therapy
Reading Intervention/Tutoring
None of the above

Please provide the location and year(s) Speech Language Therapy was provided. *

Please provide the location and year(s) Occupational Therapy was provided. *

Please provide the location and year(s) Reading Tutoring and/or Intervention was provided *

Do you have documentation (reports, treatment summaries, goals, etc.) from previous therapies? *

Yes
No

Does the client enjoy or avoid the company of other children? *

Generally Enjoys
Generally Avoids

Does the client make eye contact with others when speaking to or interacting with? *

Is the client aware of, or frustrated by any speech / language difficulties? Please explain. *

What are your concerns regarding communication? *

What are the client's strengths? *

What are the client's weaknesses? *

What are the client's interests? *

How does the client feel about reading?

What struggles does the client experience with reading? (i.e. in your opinion and/or from what the school/teacher have brought to your attention, etc.)

Is the client aware of their difficulties with reading?

Have their struggles with reading affected their confidence? If so, how?

What instructional and/or assessment programs does the client's school use?

Does the client have sustained attention? (i.e. is the client able to sit at a table for a length of time, do they struggle with sitting still, etc.)

Does the client experience dysregulation either while reading or trying to read?

How would you rate the client's listening ability when given simple instructions either at home or at school?

When the client gets upset, do they act agressively towards other people, themselves or property? (i.e. do they hit, kick, bite, pinch, scratch, push, throw objects, threaten or break objects, etc.)

DEVELOPMENTAL MILESTONES

Please provide the approximate age in months the client achieved the following developmental milestones:

Sat alone (unassisted) *

Babbles *

Said first words *

Put two words together *

Spoke in short sentences *

Grasped a crayon or pencil *

Walked *

Toilet trained *

How did you hear about us? *

Please share how you heard about us.

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Reading Intervention Form

What is Reading Intervention Therapy?

To sign up for any Reading Tutoring/Intervention sessions with Lindsay Munroe, Reg. Educator - Reading Specialist, please fill out the form below.

CLIENT INFORMATION

EDUCATION

MEDICAL HISTORY

SPEECH, LANGUAGE & OCCUPATIONAL CONCERNS

DEVELOPMENTAL MILESTONES