Student Services Information Form So we can get a full picture of your child’s needs, please fill out the form below or call our Edmonton centre at 780-499-6472. Name * First Name Last Name Phone * (###) ### #### Email * What is the preferred time of day you are looking for? * Are you also open to daytime spots? What is the age of your child? * Grade completed as of last June? * Is your child in French immersion? * Yes No Does your child speak English as a first language? * Yes No Does your child speak other languages at home? * Yes No Does this child receive learning assistance services at their school? * Yes No Has your child had any educational assessments? * Yes No Does your child have any allergies? * Yes No Does your child have any other medical issues? * Yes No Has your child's visual or hearing acuity been assessed? * Click all that apply Yes, visual acuity. Yes, hearing acuity. No Does your child suffer anxiety in any circumstances? * Yes No Does your child exhibit behavioural difficulties at home or at school? * Yes No Does your child exhibit attentional difficulties at home or at school? * Yes No Does your child take any medications or supplements? * Yes No Does your child exhibit compulsive behaviours or tics? * Yes No Please add any more information that might be helpful. * Where you referred to Reach? * Yes No Thank you! Our Ottawa Director will get back to you shortly.
