First Name *

Last Name *

Phone *

Email *

By providing my phone number, I agree to receive text messages about my application or appointment.

What grade is your child in? *

Grade 5 or below

Grade 6 or above

Is your child reading below grade level? *

Yes

How far below grade level is your child reading? *

Not behind

1 to 3 levels behind

More than 3 levels behind

Does your child receive phonics instruction at school? *

Yes

No - my child’s school relies mostly on sight words and memorization for reading instruction

I don't know

Does your child receive reading support at school? *

Yes, they have an IEP for reading and sees a reading specialist

Yes, only extra help from the classroom teacher/para

How often does your child receive reading support at school? *

Daily

3+ days/week

2 days/week

1 day/week

Is your child diagnosed with a significant learning disability? (Please NO DOT select Yes for mild to moderate ADHD or dyslexia) *

Yes

Your child may be a fit for Literacy Tree, and this will be determined during your call with our specialist.

Because our program delivers results in each 12-week class, Literacy Tree selects only a limited number of applicants per cycle.

If you and we both decide the program is a fit to address your child's reading gaps and you're given the opportunity for your child to enroll in our 12-week program, are you willing to invest the time, money and energy it takes to make sure your child is successful in the program?

Yes, I am willing to invest the time, money and energy to make sure my child is successful in the program.

Yes, I am willing to invest the time, money and energy to make sure my child is successful in the program but I may need a financing option.

No at this time I cannot invest the time, money and energy to make sure my child is successful in the program.

Please let us know what specific concerns you have about your child's reading progress:

This background information will help us to make the most of our time on your call *

If you are offered enrollment and decide to proceed, how soon will you be ready to start tutoring to boost your child’s reading level over 12 weeks? *

Within the next 1-4 weeks

Within the next 4-8 weeks

Not sure when I would want my child to begin

Does your child have an IEP? If so, please have it available for the reading consultation. *

Yes, my child has an IEP

No, my child does not have an IEP

By scheduling this appointment, you are committing to showing up, at the scheduled time, in a location where you can speak undistracted about fixing your child's reading gap

I agree to cancel or re-schedule 24 hours in advance if I will not make this meeting for any reason *

I Agree

I cannot make this commitment at this time

If I do not cancel or reschedule in advance, I will be a "no-show". I understand that Literacy Tree cannot re-book no-shows, since they take time away from other parents to meet with our teachers, and no-show parents tend not to have the commitment needed to make their child successful in the program. *

I Understand

It may be best for me to try again in the future when I have more time