Family Intake Form - Rooted Readers

Child's information

Child's full name

Date of birth

Current grade

Current school

Parent / guardian information

Full name

Relationship to child

Phone number

Email address

Preferred contact method

Phone call Text Email

About your reader

Main concerns (select all that apply)

Letter / sound recognition Fluency Decoding Comprehension Spelling Reading avoidance / anxiety

Other concerns

How long have you noticed these challenges?

Less than 6 months 6–12 months 1–2 years 2+ years

Has your child been evaluated for a learning difference? (dyslexia, IEP, 504, speech/language)

No Yes

Is your child currently receiving other reading support?

No Yes

What does your child enjoy? (interests, hobbies, favorite topics)

This helps personalize sessions with books and materials your child will actually love.

Scheduling preferences

Preferred days

Mon Tue Wed Thu Fri Sat

Preferred time of day

Morning Afternoon Evening

Session format

In-person Online No preference

Anything else?

Is there anything else you'd like me to know before our consultation?