Dyslexia Parent Referral - Student Services

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Parent Referral for Dyslexia Screening

*This referral is for a Level One screening for the characteristics of dyslexia. This screening does not diagnose Dyslexia.

* Indicates required field

Select School *

Your Name *

First

Last

Relationship to Student *

Email *

Name of Student *

First

Last

Phone Number *

Grade *

Place a check beside each behavior observed at home or in the classroom. *

Difficulty learning and remembering the names of he letters in the alphabet. Difficulty sequencing the alphabet orally or in writing. Difficulty associating letters with sounds, such as the letter t with the /t/ sound. Difficulty recognizing and generating rhyming patterns. Diffculty pulling words apart into individual sounds. (ex. mat /m/ /a/ /t/). Difficulty with blending sounds to form words. Very slow in acquiring reading skills. Makes guesses on unfamiliar words in reading. Problems keeping place on page when reading. Deficient word attack skills. Failure to understand what he / she reads. Difficulty using the correct short vowels in spelling words. Has trouble spelling words correctly in a sentence. Makes spelling errors that involve changing the order of letters within a word. Difficulty with finding the right word to say and / or seems to hesitate when trying to answer a question. Spelling, reading, writing skills are below what you would expect in view of perceived intellectual ability. Any family history of reading difficulties.

Reasons for Referral *

Student's Strengths *

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