Parent Form for Reports

Please complete this form and upload a copy of your child's report.

You will receive an oral report from Dr. Kaufman via telephone. You may record the conversation. The oral report will consist of a review of the report(s) you send us and will be 15-30 minutes in length.

The cost of this service is $39.00 to review a report up to 10 pages and $3.00 per page for any additional pages.

Child's Name*
First Last
Child’s Date of Birth*
Child's Age*
Child’s Grade*
Why was your child evaluated?*
Has your child ever been retained in a grade?*
If so, what grade?*
Does your child currently receive help for reading?*
Has your child ever received help for reading?*
If so, please describe that help (e.g.: how frequently, was it in a group or individually, what type of help was it, how long has he received help?)*
Is your child on an IEP?*
If so, please describe the services*
Use this space to tell us any other information you would like us to know about your child
Parent’s Name*
First Last
Parent’s Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address (to be used for scheduling)*
Phone Number*
Upload a Copy of Your Child's Report*
Using the area below please upload a copy of your child's report from your computer.
Accepted file types: pdf, png, jpg.
Other Reports*
Are there other evaluation reports that exist for your child?
- Yes
- No
Other Report #1*
Evaluation type
Other Report #1*
Date completed
Other Report #2
Evaluation type
Other Report #2
Date completed
Other Report #3
Evaluation type
Other Report #3
Date completed
Other Report #4
Evaluation type
Other Report #4
Date completed
Comments
This field is for validation purposes and should be left unchanged.

Parent Form for Reports

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