Case History Form

Client / Student Name*
First Last
Date of Birth*
Month
Day
Year
Current Age*
Current Grade*
Client / Student's School Name
Client / Student Teacher's Name
Parent / Guardian Information
Person Responsible For Client / Student*
First Last
Date of Birth*
Month
Day
Year
Billing Address*
Street Address City State ZIP Code
Email*
Occupation
Best Contact Phone - Example (xxx-xxx-xxxx)*
Alternate Contact Phone - Example (xxx-xxx-xxxx)
Would you like to receive text message updates?*
- Yes
- No
Secondary Parent / Guardian Name
First Last
Occupation
Best Contact Phone - Example (xxx-xxx-xxxx)
Email
Student / Client Background Information
Has your child's teacher ever expressed concern about your child's learning or behaviors?*
- Yes
- No
If "yes" please explain:*
Is your child currently in an alternate classroom placement for reading or mathematics? (small group, school intervention)*
- Yes
- No
If "yes" please explain:*
Tell us what difficulty the student is having with learning? (check all that apply)*
- Reading
- Math
- Writing
- Homework / Study Skills
Has your child exhibited signs of or been diagnosed with: (Check All That Apply)*
- None
- ADD / ADHD
- Frustration / Dislike School
- Cognitive Delay (known IQ below 70)
- Been Retained a Grade
- TBI
- Brain Tumors
- Seizures
- Autism Spectrum Disorder
- Had any Psychological Testing
- Been on an IEP or 504 Plan
- Hearing or Speech Difficulties
- Reverse Letters or Numbers
Briefly describe your child's educational history*
Does the student have any other academic difficulties? (study skills, organization, other)*
- Yes
- No
If yes please explain*
Does the student have any allergies?*
- Yes
- No
If yes please explain*
Please tell us how you heard about Turning Leaf Literacy Center?
- A friend
- A teacher
- Internet or Website
- Other
If "other" please explain*

Wasilla Center Location

907-373-2888

907 373-2896

690 E Susitna Ave

Wasilla, Alaska 99654

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*Turning Leaf Literacy Center is NOT Lindamood-Bell Learning Processes nor is it affiliated with, certified, endorsed, licensed, monitored or sponsored by Lindamood-Bell, Nanci Bell, Phyllis Lindamood or Pat Lindamood. Lindamood-Bell – an international organization creating and implementing instructional methods and programs for quality intervention to advance language and literacy skills – in no way endorses or monitors the services provided by Turning Leaf Literacy Center.

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Case History Form

Parent / Guardian Information

Student / Client Background Information