New Student Registration

Welcome to Northwest Reading Clinic!
If you have scheduled a testing with us please FULLY complete the following form on the day you book your appointment.
If you have not yet scheduled a testing, please contact us to do so before filling out the form below.
*Please note this form is easier to navigate on a desktop than on a phone.

* Indicates required field

Student Name *

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Last

STUDENT AGE & GRADE *

Guardian's Name *

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Last

Mailing Address *

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Line 2

City

State

Zip Code

Country

STUDENT BIRTHDATE *

Second Guardian's Name *

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Last

Billing Address *

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Line 2

City

State

Zip Code

Country

Contact Email(s) *

Phone *

Secondary Phone *

Google Meets Contact *

For online testing and/or treatment, please tell us the email address you will be using to connect with your clinician via chat.google.com. We will use this information to look you up ahead of the testing and send your contact to the examiner in Google Meets.

We would like to know more about your student's background & education. Please use the field below to tell us more about the following.

Student Background Info *

As guardian I accept financial responsibilty for all costs incurred at Northwest Reading Clinic, Inc. *

Yes

What school does your student attend? Who is their teacher? Do they attend special classes? Are they on an IEP or 504 plan? Have they ever repeated or skipped a grade?

How is reading, spelling, comprehension and math: Up to speed, so-so, or far behind?

Please also comment on your student's history, including any difficulties, special therapies, previous intervention, attention, behavior and/or self-image problems. Are they on medication for ADD, ADHD, anxiety, or other conditions?

What would you like us to look for when testing? Is there something you've noticed or wondered about? What does your student struggle with, and what are their strengths?

I understand that NWRC requires clients to provide at least 24 hours' notice when cancelling or rescheduling testings, and that no-shows or cancellations outside of this window will result in a $100 cancellation fee, to which our usual payment policies apply.

I agree. *

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