Name of Child *

First Name

Last Name

Phone *

(###)

###

####

Reading *

(Select all that apply)

Unable to read for longer than five minutes at a time

Able to read for up to 15 minutes in one sitting

Able to read for up to 30 minutes in one sitting

Able to read for up to 60 minutes in one sitting

Unable to comprehend what was read

Able to comprehend what was read, but troubles with articulating response

Able to comprehend what was read, but troubles with remembering soon after reading material

Able to comprehend what was read and can discuss up to 30 minutes after reading material

Able to comprehend what was read and can discuss up to 60 minutes after reading material

Able to comprehend what was read and can discuss at any point in time after reading material

Learning English as a second language

Writing *

(Select all that apply)

Have issues with spelling, but can write full sentences

Have issues with spelling and cannot write full sentences

Have little to no issues with spelling, but cannot write full sentences

Have little to no issues with spelling or writing full sentences

Can write full sentences, but have issues writing full paragraphs

Can write full paragraphs

Can write responses to questions regarding reading material

Have issues writing responses to questions regarding reading material

Can write responses to questions asked orally

Have issues writing responses to questions asked orally

Can write responses to questions regarding a picture

Have issues writing responses to questions regarding a picture

Understand the parts of speech/parts of a sentence

Tend to mix up parts of speech/parts of a sentence when asked

Learning English as a second language