Contact Us

Please take this opportunity to give us as much information as you wish to help us answer your questions as fully and completely as possible. While some choices may not apply exactly, please check the answers that best fit your situation. Be sure to specify if you would like to arrange for a free consultation.


Name of Parent(s) or Guardian(s) (req'd if Client is under 18):

Primary Email Address:
Home phone:
Cell phone:
Work phone:
Address 1:
Address 2:
City:
State:
Zip:
Country:
Fax:

Client Name:
Client Age:
Client Date of Birth:

Please provide a brief description of the current struggle(s) that the Client is experiencing.

Please select (check) all that apply to the client's current struggles:
	Difficulty with Reading	Difficulty with Math
	Slow Reader	Has trouble self-starting
	Dislikes Reading	Difficulty completing homework
	Poor Reading Comprehension	Fails to hand in assignments
	Poor Spelling	Difficulty finishing projects
	Poor handwriting	Test anxiety or nervousness
	Difficulty with writing/composition	Dislikes school
	Difficulty memorizing vocabulary	Suspect Dyslexia
	Difficulty memorizing multiplication table	Suspect ADD or ADHD

Please select (check) all that apply:
	Excellent Reader (above Grade level)	Enjoys skateboarding, snowboarding, skiing, BMX'ing or similar activities
	Excellent at Math (above grade level)	Enjoys video or computer games
	Enjoys Reading	Good at remembering where things are
	Enjoys Math	Good at puzzles
	Enjoys Science	Above average intelligence
	Enjoys History or Social Studies	Enjoys learning
	Enjoys physical activity	Very social
	Enjoys Art	Good at multi-tasking
	Enjoys music	Other

Please describe any other talents or abilities demonstrated by the client:

Please describe any other interests, activities or areas of study that the client enjoys:

Please select (check) all that apply to the client's current struggles:
	Delayed speech or language skills	Fear of school or work
	Avoids eye contact	Fear of social situations or groups
	Difficulty following instructions	Fear of heights or bridges
	Generally or often inattentive	Fear of the Dark
	Sensative to clothing or touch	Other Fears or Phobias
	Over reacts to changes in routine or schedule	Frequent bedwetting
	Sensative to criticism	Frequent nightmares or night terrors
	Difficulty sleeping	Alergies
	Poor Diet, over or under weight	Frequent headaches or migraines
	Low self-esteem	Obsessive or Compulsive behaviors

Please describe any behavior or emotional issues that you feel might be relevant:

In your own words, please describe any significant emotional events during the most recent 3 years:

Is the client currently under the care of a physician, psychotherapist, pathologist or licensed medical practitioner?

If yes, please explain the condition(s) for which the client is being treated and the nature of the treatment(s), including any medications.

Please include any additional information which you believe may be relevant to the current struggle(s):

Please describe as clearly as possible the results that you (the client) would like to achieve.

How did you hear about us?

Thank you for completing your information profile. Please take a moment to review your answers and add any information that you feel is relevant to achieving your desired results.