Literacy Intervention

First name of person completing this form

Email

Age of person seeking literacy intervention

The majority of clients we serve are students entering K - 8th - those older than this range are addressed on a case by case basis.

Referred by (if applicable)

Are you willing to go with a different option if your preferred location is not available yet?

If yes, which one?

Any other scheduling comments you’d like us to take into consideration?

Briefly describe reason for seeking literacy intervention

What are you hoping to accomplish?

Has your student received any prior private reading intervention or instruction? If yes, can you please briefly describe?

Donation

Our "donate what you can" model supports families of all income levels. We suggest a donation between $55-$65 per literacy intervention session. This covers the operating costs to run each session and pays back into the Client Assistance Fund. Keep in mind the following when determining your pledge: - $50 covers the cost of running each session. - Anything pledged over that amount goes in our Client Assistance Fund to help other families in our community who are seeking a similar service. - This is a tax-deductible donation. - Other providers typically charge cash pay clients $100+ for a similar service. If you are not in a position to give the suggested donation, we ask you give what you can. The Client Assistance Fund (CAF) - built up by donors, grantees and fundraisers - is an instrumental part of providing financial assistance to families. Suggested donations towards literacy intervention are reviewed by our Board of Directors and approved based on the balance in our CAF. Donations can be made via cash, check, debit or credit card. You will receive a donation receipt for the full amount pledged.

Other Amount

Put N/A if already selected above

Client Agreement

The best experience happens when both client and Literacy Specialist work together. We ask that you commit to the following: 1. Committing to the process - when you sign up for intervention you are committing to a 3-month period of time at which case we will determine if all parties are able to commit to another 3-month period. Typically, intervention takes 18-36 months. The timeline can vary based on a variety of factors we are happy to discuss with you. 2. Keeping your appointments (30-minute sessions twice a week) - if you miss more than 2 sessions (with the exception of holidays and sickness) you will be removed from the schedule and added back onto the waitlist. 3. Completing your homework assignments. 4. Paying your bill as soon as it is received. If missed or late payments become the norm you will be removed from the schedule and added back onto the waitlist. If you have read, understand, and agree to all of the above statements - your name in the box below will serve as your signature: (If the client is a minor, please sign as the parent/guardian)

We’re always accepting donations…

Welcome! We’re glad you found us!