Name of Student

      Last Name      

     First Name      

    Middle Name  

 Your Date of Birth (MM/DD/YYYY) Grade in School

 Name of School

 Is your child diagnosed L.D.?  or ADHD/ADD? (If so, please check one.)

 A copy of the report that diagnoses the Learning Disability/Attention-Deficit Disorder must be     enclosed. Please type the report on the following:

 Name of Responsible Parent or Party

 Street Address

 City   State

 Zip Code

 Employer

 Responsible Party’s Social Security Number  

 Phone (Home) (Work)

 (Cell) (Other)

 Email Address 

 Additional Parent’s Name

 Father's Name 

 Mother's Name

 Phone (Home) (Work)

 (Cell) (Other)

 Email Address 

 Contact in case of emergency   Phone

 Name of Doctor Phone

 Allergies

 Medical conditions to be aware of

Cost:   $30.00 per session to be paid at the first of each month.  Payment may be made by cash, check, MasterCard, or Visa.

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