Assessment Information Form Contact Information Person1Contactform Name of person completing this form Name of person completing this form First Name First Name Last Name Last Name 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 Student Name First Name First Name Last Name Last Name If minor, name of parent/guardian (If not a minor put NA for both first and last name) If minor, name of parent/guardian (If not a minor put NA for both first and last name) First Name First Name Last Name Last Name Date of Birth * Grade * Current School * 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 Information Has student ever been tested for learning difficulties? If yes, when and where? * 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? * 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 Submit If you are human, leave this field blank.
