Learning Differences and ADHD Testing Information Form Student's name:(Required) First Last Tester(s):(Required)Birth date:(Required)School:(Required)Grade:(Required)Name of Parent or Guardian #1:(Required) First Last Name of Parent or Guardian #2 (Optional): First Last Primary Phone Number:(Required)Home Address:(Required) Street Address Address Line 2 City State ZIP / Postal Code Mobile Phone (Parent 1):(Required)Mobile Phone (Parent 2):(Required)Email Address (Parent 1):(Required) Email Address (Parent 2):(Required) Student Mobile Phone (optional):Student Email Address (optional): Please indicate a contact preference order (1, 2, 3, etc.) for all phone numbers, home and/or mobile:(Required)Primary PhoneMobile Phone (Parent 1)Mobile Phone (Parent 2)Student PhoneIs email a reliable way to communicate with you?(Required) Yes No May we contact you via email with QWERTY-related news? (2-3 times yearly)(Required) Yes No Do you use Facebook?(Required) Yes No Do you use Nextdoor?(Required) Yes No Have you ever written a Yelp! review?(Required) Yes No Alternate contact(s) in case of emergency (name, relationship, contact phone #):(Required)Are there any medical concerns to be aware of while this student is working at QWERTY (possible diabetic reaction, seizures, allergies, etc.)?(Required)Enter "None" if none.Special instructions in the event of a medical or other emergency:(Required)Please confirm your EMAIL address for billing (PDF format):(Required)(Write "Paper" if you prefer bills sent via USPS to your home address):Billing: A $1000 down payment for testing is due on the day testing begins. The balance of remaining payment is due during the month in which your PDF invoice is received by mail or email. We encourage email to save paper. Please make certain that the following email address is saved in your address book: quickbooks@notifications.intuit.com. You will receive a final copy of the testing results once the balance of payment is received. A non-optional late fee of 1.5% will be added for payments received after the due date. Payment 2 months late are subject to an additional 1.5% late fee, and 3 months late will be subject to an additional 1.5% late fee. Your prompt payment helps simplify our accounting and is sincerely appreciated.Fees: Educational Testing Fees are determined by total number of hours testing, scoring, and writing the report. The Psychologist rate is $250/hr and the Learning Specialist rate is $190/hr. An additional Administrative Testing Fee is also added ($200) that covers materials, billing and other costs. Scheduling and Cancellation: Please phone as far in advance as possible if you are unable to keep a scheduled appointment, providing the reason for the absence. You will be billed for one hour of time for appointments missed without reasonable notice. Since holiday schedules vary in different schools, it is your responsibility to confirm your schedule for those days.Please type your full name to certify that you have read and understand the above.(Required) First Last Today's Date(Required) MM slash DD slash YYYY How did you hear about us?Did you learn about us from another past or present family that has worked with us?(Required) Yes No Name(Required) First Last Were you referred to QWERTY by a professional? (Teacher/Education Professional/Other).(Required) Yes No Name(Required) First Last What is this person's profession? (Teacher/Educational Professional/Other).(Required)Did you hear about QWERTY through a Website or Social Media? (please select all that apply)(Required) Google Search Bing/Yahoo Other Search Engine Facebook Twitter Nextdoor Yelp! Instagram Other None Search words used (if known):(Required)Other Referral Source (please specify):(Required) Areas we serve We regularly coach students living in: Atherton Cupertino Emerald Hills Los Altos Menlo Park Mountain View Palo Alto Portola Valley Redwood City San Mateo San Carlos Santa Clara Sunnyvale Stanford Woodside
