Parent's Name *

First Name

Last Name

Parent's Phone *

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Main Reasons for Seeking Services (check all that apply) *

Giftedness

Underchallenge

Inattention

Executive dysfunction (challenge with self-management)

Behavior issues

Anxiety

Perfectionism

Reading difficulties (rate and/or comprehension)

Poor handwriting and fine-motor skills

Writing difficulties (production and/or organization)

Math difficulties (concepts, fact acquisition, and/or application)

Memory difficulties

Slow processing

Other