Dyslexia Tutoring Program

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Dyslexia Tutoring Program

Home
About
Tutors
Students
News & Events
Resources
Contact
Donate

APPLY

VOLUNTEER

DONATE

Adult Intake And Screening

DTP’s tutoring program is designed specifically for people with a dyslexic learning style.
There are many reasons why you might have trouble reading. Our application process helps us determine if DTP can help you with your reading difficulties.

Once we receive your Intake, we’ll email you a list of materials we need to verify your financial eligibility and evaluate you for services. You have 4 weeks from the date of that email to submit these documents to DTP. You must submit all required materials by the specified deadline to be considered for services.

Completing this Intake is the first step in applying for services. You must complete all fields on this form.

GENERAL INFORMATION

Name(Required)

First Last

Email(Required)

Student Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please provide at least one phone number below:(Required)

Cell Phone

Home Phone

Work Phone

Cell Phone(Required)

Home Phone(Required)

Work Phone(Required)

Would you like to receive text messages regarding the status of your application?

Yes, I would like to receive text messages regarding the status of my application.

By selecting yes, you agree to receive text messages from Dyslexia Tutoring Program related to tutoring services. Message & data rates may apply. Message frequency varies. Reply HELP for help and STOP to cancel.

Relationship to the applicant/student:(Required)

Please specify your relationship to the applicant/student.(Required)

Referred By:(Required)

Referred By: Other(Required)

Please provide referral details.

Tell Us Why You Are Seeking Help(Required)

Annual Household Income(Required)

Note: We require documentation (e.g., most recent income tax return/Form 1040; most recent paystub; government benefits award letter) to verify your income and financial eligibility for our free services.

Number of Household Members(Required)

Highest Grade Completed(Required)

Race(Required)

Gender(Required)

In case of emergency, please contact: Primary Contact Name(Required)

First Last

Primary Contact Phone(Required)

Secondary Contact Name (Optional)

First Last

Secondary Contact Phone

What days/times would you be available to meet with a tutor for one hour?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday Time(s)(Required)

Tuesday Time(s)(Required)

Wednesday Time(s)(Required)

Thursday Time(s)(Required)

Friday Time(s)(Required)

Saturday Time(s)(Required)

Sunday Time(s)(Required)

Please list the locations where you could meet with a tutor.

Closest Libraries(Required)

School (Name)(Required)

Community Center (Name or location)(Required)

DTP’s offices at the Rotunda?(Required)

Yes

INTAKE - GENERAL

Have you ever been diagnosed with a learning disability?(Required)

Yes

Is there a history of learning disabilities in your family?(Required)

Yes

I Don’t Know

Have you had any educational evaluations?(Required)

Yes

If yes: you will need to provide copies of these evaluations to be considered for services.

Have you had any psychological or psychiatric evaluations?(Required)

Yes

If yes: you will need to provide copies of these evaluations to be considered for services.

INTAKE - READING

Are you experiencing reading difficulty?(Required)

Yes

Do you know letter sounds?(Required)

Yes

Are you able to sound out (decode) words?(Required)

Yes

Do you reverse letters when reading? For example, do you see a “b” instead of a “d” in words when reading?(Required)

Yes

Do you switch the position (transpose) of letters within words when reading? For example, do you see, “taepot” instead of “teapot?”(Required)

Yes

Are you able to blend letter sounds? For example, can you blend “b” and “l” as in b̲l̲ack, b̲l̲ue, b̲l̲oom?(Required)

Yes

INTAKE - WRITING & SPELLING

Do you experience problems writing?(Required)

Yes

Is your writing legible?(Required)

Yes

Somewhat

Do you reverse letters when writing?(Required)

Yes

Do you have problems spelling?(Required)

Yes

Can you write in:(Required)

Cursive

Both

Neither

INTAKE - SPEECH, HEARING & VISION

Do you have speech problems?(Required)

Yes

Have you ever received speech or language services?(Required)

Yes

Do you have hearing problems?(Required)

Yes

Do you have vision problems?(Required)

Yes

INTAKE - HEALTH

Do you have any allergies?(Required)

Yes

If yes, please list allergies(Required)

Have you been diagnosed with ADD or ADHD?(Required)

Yes

Do you have any medical conditions we should be aware of?(Required)

Yes

If so, please explain:(Required)

Have you ever had lead poisoning?(Required)

Yes

Are you currently taking any medications?(Required)

Yes

If yes, please list:(Required)

INTAKE - CONSENT & DISCLOSURES

Do you have any prior convictions?(Required)

Yes

Do you consent to a background check?(Required)

Yes

This field is hidden when viewing the form

Have you had a recent psychological assessment within the last two years?(Required)

Yes

This field is hidden when viewing the form

If yes, when and where(Required)

This field is hidden when viewing the form

Have you had a recent educational assessment within the last two years?(Required)

Yes

This field is hidden when viewing the form

If yes, when and where(Required)

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Help Someone in Need Get the Support They Deserve.

Your donation to DTP dismantles financial barriers to literacy for individuals from low-income and strategically under-invested communities. By providing access to this fundamental skill, every dollar you give becomes an investment in a more equitable and prosperous future for us all.

DONATE TODAY

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