Adult Request for Services
This form is for adult inquiries.

Please click the ‘request service’ tab if you are seeking services for a child.

Thank you for your interest in the Dyslexia Resource Center. While our center is focused primarily on children with reading difficulties, we regularly receive requests from adults seeking help with reading. We will do everything we can to help you find resources for your situation.

Please complete and submit the form below. Once we have received your completed Request for Services form, we will be in contact within three business days.

If you are concerned we did not receive your form, please email us at info@dyslexiasc.org.

Your Name

First Name

Last Name

Best Contact Number

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

YYYY

ACADEMIC HISTORY

What is the highest grade you completed?

Select One

Were you ever retained? If so, what grade(s)?

I attended school at:

Check all that apply.

Public school

Private school

Home school

Online school

Other

Which hand do you use for writing?

What are your strengths:

What are your weaknesses:

RELEVANT HEALTH HISTORY

Birth

Select One

If a preemie, how early?

Any complications at birth?

If none, write NONE. If not known, write NOT KNOWN

Early Developmental Milestones met?

If no, please list those not met:

Ear infections or other conditions that might affect speech, hearing, or development?

If none, write NONE

List any emotional or behavioral problems:

If none, write NONE.

Known allergies:

Food? Other? Asthma? If none, write NONE.

Do you have ADD/ADHD?

Do you take medication for ADD/ADHD?

Please list any medications you take regularly:

If none, write NONE.

Do you wear or need glasses/contacts?

Do you have any hearing or speech impairments?

Birth Order

Who else in your family has/had trouble with reading or spelling?

Life Impact

How are your reading difficulties impacting your life?

What are you currently doing, or have you tried, to help with reading/spelling?

Have you attended a Helpful HInts for Reading workshop?

How did you learn about the Dyslexia Resource Center?

Adult Request for Services This form is for adult inquiries.

Please click the ‘request service’ tab if you are seeking services for a child.

Adult Request for Services
This form is for adult inquiries.