Learning Differences and ADHD Testing Information Form

Student's name:*

First Last

Tester(s):*

Birth date:*

School:*

Grade:*

Name of Parent or Guardian #1:*

First Last

Name of Parent or Guardian #2 (Optional):

First Last

Primary Phone Number:*

Home Address:*

Street Address Address Line 2 City State ZIP / Postal Code

Mobile Phone (Parent 1):*

Mobile Phone (Parent 2):*

Email Address (Parent 1):*

Email Address (Parent 2):*

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:*

Primary Phone	Mobile Phone (Parent 1)	Mobile Phone (Parent 2)	Student Phone

Is email a reliable way to communicate with you?*

Yes
No

May we contact you via email with QWERTY-related news? (2-3 times yearly)*

Yes
No

Do you use Facebook?*

Yes
No

Do you use Nextdoor?*

Yes
No

Have you ever written a Yelp! review?*

Yes
No

Alternate contact(s) in case of emergency (name, relationship, contact phone #):*

Are there any medical concerns to be aware of while this student is working at QWERTY (possible diabetic reaction, seizures, allergies, etc.)?*

Enter "None" if none.

Special instructions in the event of a medical or other emergency:*

Please confirm your EMAIL address for billing (PDF format):*

(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.*

First Last

Today's Date*

How did you hear about us?

Did you learn about us from another past or present family that has worked with us?*

Yes
No

Name*

First Last

Were you referred to QWERTY by a professional? (Teacher/Education Professional/Other).*

Yes
No

Name*

First Last

What is this person's profession? (Teacher/Educational Professional/Other).*

Did you hear about QWERTY through a Website or Social Media? (please select all that apply)*

Search words used (if known):*

Other Referral Source (please specify):*

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