The Prentice School

ONLINE INQUIRY FORM

Please complete this form to receive more information about The Prentice School. Mandatory fields marked *

Contact Information

Educational Information

Student First Name * : Student Last Name * :
* Male Female
Student's Date of Birth *:
Present School/District *: Class Size *:
Current Grade * : If retained, what grade
Family history of dyslexia or language learning difficulties? * :
Has student had any psychoeducational/neurological testing/assessments done? * :
Does student have IEP? * :
Please select school/class type and any services utilized currently or in the past (Select ALL that apply):
School/Class Type
Public School
RSC
SDC
Private Day School
Homeschool
Online Academy
Other
None
N/A
Services utilized
Speech / Lang Therapy
Tutoring
Lindamood Bell
Kumon
Occupational Therapy
Physical Therapy
Medication
Social Skills
Vision Therapy
Other
None
How did you hear about The Prentice School? *
Please include details about referral: *
(i.e. search engine, neighbor, psychologist, etc.)
Brief Academic History & Relevant Information:
Please include learning challenges and strengths. Also list any details about current services, i.e. reason for service, frequency, medication names, therapy goals, etc.