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*Person Completing Form: Student's Name:
*Phone: Student's Current Grade:
*Email: Age:
Please briefly list the primary area(s) that your student is experiencing difficulty:
Reading     Spelling     Writing     Reading Comprehension     Mathematics    
Prior diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) or ADD? YesNo
If YES, describe treatment:
Did this student require any of the following related services?
Speech and/or Language Therapy Yes No          Occupational Therapy Yes No
List any additional special education or remedial services provided to this student in the past:
Is there anything else you would like us to know?
your infomation stays confidential. We don't spam. Ever.

  • Potential
  • Discovery
  • Outlook

From Orton-Gillingham remedial instruction after-school to home school support, The Prospect Centre assists the learning-challenged student by discovering how he or she learns, then moving forward with solutions that compliment curricula as well as provide a life-long foundation of learning confidence.