New Student Inquiry
Please complete the following information about parent/guardian and child in order for us to get started with your child's registration or send us an inquiry.
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Email
Parent/Guardian Mobile Phone
Home Phone
Address
City
State
Zip
How did you hear about Launch Learning Clinic?
Friends
Family
Doctor Referral
Website
Social Media
Other
How would you prefer to be contacted?
Phone call
Text message
Email
Student
Student First Name
Student Last Name
Student Birth Date
School Student Attends
Current or most recently completed
What academic challenges is your student currently experiencing?
Does your child have an IEP? And/or, has your child had a private evaluation for dyslexia/learning disability? Please describe, and send us a copy of any IEP or evaluation.
Which service(s) are you interested in? Select all that apply. Therapy services are for students with moderate to severe learning challenges. Skills groups are for students who need just a little extra support.
Reading Therapy
Math Therapy
Reading Skills Group
Math Skills Group
Writing Skills Group
Study Skills Group
Advocacy
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