Name *

First Name

Last Name

Phone

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Background Information and Characteristics

Family history of dyslexia or learning challenges

Student is performing poorly in the classroom

Student progress monitoring data shows slow or poor rate of improvement

Kindergarten

Late learning to talk or slow to learn new words

Trouble pronouncing speech sounds (such as /th/, /r/, /l/ and /w/)

Mixing up the sounds and syllables in long words (says “aminal for “animal”)

Avoids letters or confuses them

Cannot recall sounds of letters

Unable to break words into separate speech sounds (cat has 3 sounds /c/ /a/ /t/)

Cannot identify or create words that rhyme

Doesn’t know letters in own name

Confused about the meaning of the word- who, what, where, when

Disinterested in books, read aloud or word play activities

Kindergarten and 1st Grade

Difficulty remembering the names of letters and recalling them quickly

Difficulty learning sound-letter correspondence

Difficulty with phonemic awareness tasks (such as blending or breaking words into separate speech sound, flash= /f/, /l/, /a/, /sh/)

Difficulty learning to recognize common words automatically (family names, names on signs or objects, high frequency words)

Poor spelling (omitting sounds, substituting sounds, adding sounds, transposal of sounds)

Difficulty remembering sequences (days of the week, month, ABCs)

Poor handwriting

2nd and 3rd Grade

Frequently misreads common high frequency words even after practice (when, went, they, their, been, to, does, said, what)

No strategies for word attack; makes wild guesses at words; relies heavily on the context or pictures in a story to “read”

Difficulty decoding words, often making single sound errors, omitting syllables, or skipping over prefixes and suffixes

Mispronunciation of long unfamiliar words

Loses place and skips over words while reading

Use imprecise language (says “stuff”)

Persistent reversals and transportations of letters, numbers, and words with similar visual appearances (such as b & d, 6 & 9, was & saw)

Spells phonetically without applying spelling rules or patterns

Poor spelling (omitting sounds, substituting sounds, adding sounds, transposal of sounds)

Spelling the same word different ways on the same page

Slow, choppy and/or inaccurate oral reading that lacks appropriate expression

Comprehension problems arising for poor word recognition

Beginning to avoid reading and writing tasks

Difficulty with math facts

4th and 6th Grades

Slow on oral reading fluency tests

Inaccurate reading of real and nonsense word lists (pem, loit, thwadge)

Poor spelling (omitting sounds, substituting sounds, adding sounds, transposal of sounds)

Poor handwriting and written expression

Avoidance of reading

Weak in reading strategies

Weak reading comprehension compared to listening comprehension

7th through 12th Grades

Slow and laborious reading

Poor spelling (omitting sounds, substituting sounds, adding sounds, transposal of sounds)

Difficulty note-taking

Overwhelmed by multiple assignments

Cannot work fast enough to cope

Lack of effective strategies for studying

Difficulty with homework completion

Difficulty with organization

Comprehension and vocabulary deficits due to lack of practice

Writes poorly and with great effort