PEDIC

If you wish to make an appointment with a psychologist/reading specialist, simply complete the form below.

1. Are you requesting an in-person session or a virtual online session?

2. How did you find out about our service?

3. Reason for requesting services:

4. Client Type:

*If you wish to request services for a classroom or school, please proceed to questions 19-22

INDIVIDUAL:

5. Name of Client:

First NameLast Name

6. Returning or New Client:

7. Client Sex:

8. Client's Residential Address:

9. Date of Birth:

10. Is Client under 18 years old?

*If ‘No’, proceed to question 14

11. School attended by Client:

12. Name(s) of Parent/Legal Guardian(s):

First NameLast Name

13. Relationship of Legal Guardian(s) to Client:

14. Contact # of Client/Legal Guardian(s):

Please enter a valid phone number.Format: (000) 000-0000.

15. Email Address of Client/Legal Guardian(s):

16. Name(s) of In-Case-of-Emergency (I.C.E) Contact Person(s):

First NameLast Name

17. Relationship of I.C.E Contact to Client:

18. Contact # of I.C.E Contact:

Please enter a valid phone number.Format: (000) 000-0000.

CLASSROOM/SCHOOL

19. Name of School:

20. School's Address:

21. School's Telephone Number:

Please enter a valid phone number.Format: (000) 000-0000.

22. School's Email Address:

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