Assessment Information Form Contact Information Name of person completing this form * First Name Last Name Cell Phone * (###) ### #### Time Zone Pacific (PDT) Mountain Standard Mountain Daylight Central (CDT) Eastern (EDT) Email * How did you hear about Rise? * Website, social media, school, friend, etc. Student Information Student Name * First Name Last Name If minor, name of parent/guardian * If not a minor put NA for both first and last name First Name Last Name Date of Birth * MM DD YYYY Grade * Current School * Has student ever been tested for learning difficulties? * If yes, when and where? Is the student currently on an IEP or 504 plan? * IEP 504 No If student is reading below grade level, at which grade level are they reading? * Medical History Has student experienced hearing, vision, or speech difficulties or been diagnosed with a physical, cognitive, or mental health condition such as ADHD, ear infections/tubes, asthma, autism spectrum, etc.? * If yes, please describe. If yes, diagnosed when and by whom? Is your student on any medications that could impact their ability to pay attention? * If yes, please describe Was there any unusual/significant issues during pregnancy/delivery, early childhood development, etc.? History of trauma? If yes, please describe. * Is there a family history of reading/learning difficulties? * Any other information you feel would be helpful? Academic Background Please identify student's strengths, interests, favorite classes, etc. * Tutoring Information (By filling out this section you are not obligated to enroll in tutoring services) Which days would the student be available for tutoring? (Select all that apply) * Monday Tuesday Wednesday Thursday Friday What is your preferred time for tutoring? (Select all that apply) * Before Noon Early afternoon Late afternoon Evening Additional scheduling needs/information Your Assessment Request has been received! You will be contacted soon by our Manager, Maggie Madsen, to schedule a time to have the free assessment done at our Kaysville, Utah location. Thanks!
