Name: Age:   Birth Date: Grade:

School Attending:

Check any symptom that applies. If you have any comments, type it in the entry box below the symptom. Submit the form for a response from our staff at Essential Learning Institute.

  Confuses or reverses letters or words.

Has poor handwriting skills

Has poor reading comprehension

Avoids reading and writing

Does little or no voluntary reading at home

Has poor enunciation of sounds

Suffers failure in spelling and other reading-related work

Is unable to perceive sounds, letters, and words correctly

Fails to complete tasks

Becomes emotionally upset about school work

Forgets assignments and tests

Homework is a frustrating, negative experience for both students and parent

Seems disorganized

Seems distracted easily

Is often impulsive or over-active

Fails to understand or remember instructions and assignments

Has low self-esteem

Additional Comments

Name of Parent(s)

E -.mail Address

Phone Number

Address

City State Zip Code

I want to order an evaluation/testing kit for my child.

I would like to schedule an evaluation at your facility in Allentown, PA.

I am interested in obtaining the therapy for my child after the evaluation is completed and the individualized LD strategy is prescribed.

In addition to the 9 month computer based therapy, I am interested in Home Schooling curriculum.

I would like to discuss my child's situation and the benefits of the ELI program with your certified personnel.

I would like an Information Packet mailed to me.