Intake Form

Family History

Concerns & Expectations

School History

Medical History - Pregnancy

Medical History - Overall & Developmental

Social Emotional Health

Academic Symptoms

Select the choice that best describes the frequency each symptom has appeared in the student:

Executive Functioning Symptoms

Select the choice that best describes the frequency each symptom has appeared in the student:

Social Emotional Symptoms

Visual Screening Symptoms

Primitive Reflex Group 1: Fear Paralysis Reflex

Primitive Reflex Group 2: Moro Reflex

Primitive Reflex Group 3: Tonic Labyrinthine Reflex

Primitive Reflex Group 4: Spinal Galant Reflex

Primitive Reflex Group 5: Asymmetrical Tonic Neck Reflex

Primitive Reflex Group 6: Symmetrical Tonic Neck Reflex

Primitive Reflex Group 7: Palmar Reflex

Release of Information Form

I hereby release ECA Therapist ________________________ to discuss pertinent information of the above-mentioned student with other educational or therapeutic professionals who work with the student for the purpose of better serving this student. These professionals may include but are not limited to the student’s teacher(s), occupational or speech/language therapist(s), psychologist(s) or pediatrician. I understand that any discussions will be handled with the greatest respect for the individual and the individual’s privacy. I further understand that any information shared is held in absolute confidence between ECA Therapist ____________________________ and said professionals.

Emergency Information

Emergency Contact

Other Emergency Contact

In the event that a parent/guardian of a family member can not be reached, I give my permission for the student to receive the necessary medical services and/or to call an ambulance. The undersigned person(s) will be responsible for medical/ambulance expenses.

Business Policies

I. Commitment

In order to achieve the goals we have established, we strongly encourage consistent attendance. While we understand that there are times life gets busy, your child will experience the best results by coming to all planned sessions on time and for the complete duration.

II. Cancellations

If you give at least twenty-four hour notice, you will not be charged for canceling a session. Without twenty-four hour notice, payment for the missed session will be invoiced. If you are late for a session, the session will still end at the appointed time and you will still be charged for a full session. If the therapist is ill or unavailable for a session, the client will be notified as soon as possible and will have the option of making up the session or crediting the missed session to the next billing.

III. Payment Schedule

Payment is expected prior to service rendered based on a payment plan agreement made with Eukarya Christian Academy.

IV. Holidays

Holidays will be indicated on the Eukarya Christian Academy School Calendar. Other vacation times will be arranged at the discretion of the Educational Therapist. Ample notice will be provided.

V. End of Services

Educational therapy forms a strong relationship between student and educational therapist. Abrupt termination of services damages that relationship and can be hurtful to a child. Thus, when parents decide that it is time to end services for any reason, four weeks notice is required. This is to allow for final assessments and to allow for closure between student and educational therapist.

Waiver and Release of Liability

I _______________________, hereby give permission for staff members of Eukarya Christian Academy to meet with my child and provide services offered by The Learning Center. I understand that I am paying for services through The Learning Center to have a specialist work with my child. By signing this form, I agree that I will not hold Eukarya Christian Academy staff or board members liable while working with my child in accordance with their services. If a medical emergency arises during a session with my child and The Learning Center staff, I understand that the staff member/specialist or designee will contact medical emergency services immediately. In addition, I will not hold the staff member/specialist liable for any medical emergency. If my child is involved in a personal injury or accident, I release and waive all liability from The Learning Center staff/specialist. Services offered are based on individual licensures and certifications in their field. Specialists in The Learning Center will not diagnose your child, nor will we prescribe medications. The Learning Center staff may make recommendations to seek outside additional professional guidance. Regarding counseling services, confidentiality is our goal in order to gain the trust of the student. Parents/guardians will be updated on the status of students in the form of progress reports, unless any information pertaining to self-harm or endangerment is divulged, parents/guardians will be notified directly. TLC offers highly effective services for students and may vary based on individual client needs; however, results are not guaranteed. I agree that I will release and waive all liability involving my child and The Learning Center staff/specialist.

Services and Schedule of Fees

Eukarya Christian Academy takes pride in the personalized, research-based support we can offer your child. Helping your child feel confident and to love learning is our goal.

A dyslexia therapist or reading specialist will personally guide your child through a multisensory program of explicit, systematic instruction for both reading and spelling. These programs are clinically diagnostic and prescriptive, multisensory, intensive, and results driven. For dyslexia, effective interventions should include training in letter sounds, phoneme awareness, and linking letters and phonemes through writing and reading from texts at the appropriate level to reinforce emergent skills.

Your child can work with a reading specialist to learn how to:

• Sound out letters and words ("phonics")
• Read more quickly
• Increased comprehension
• Write more clearly

A couple of reading programs that are geared toward kids with dyslexia:

• Orton-Gillingham. This is a step-by-step technique that teaches kids how to match letters with sounds, and recognize letter sounds in words.
• Multisensory instruction teaches kids how to use all of their senses – touch, sight, hearing, smell, and movement – to learn new skills. For example, your child might run their finger over letters made from sandpaper to learn how to spell.

Dyscalculia: A trained specialist will work with your student to identify this learning challenge and provide remediation. Persons with dyscalculia have marked, persistent problems in applying the basic methods of arithmetic and in knowledge of math facts (the multiplication table).

Initial Intake/Assessment:

Includes consultation with students, parents, teachers, student's doctors and psychologists to assess student's current social-emotional functioning and determine appropriate therapeutic strategies and interventions to address needs.

Counseling/Behavioral Coaching:

Includes individual counseling/coaching and/or group counseling to address social- emotional needs related to anxiety/depression, ADHD/ADD, anger management, impulse control, self-esteem, interpersonal skill deficits.

Quarterly meetings with parents and case management.

For our current schedule of fees and information, please view TLC Fees and Information.

(behavioral therapy and reading remediation, therapy for dyslexia, dysgraphia, dyscalculia)

For our current schedule of fees and information, please view TLC Fees and Information.

Occupational Therapy

School based occupational therapy practitioners support academic achievement and social participation by promoting occupation within all school routines. Therapy provided within the school setting is designed to enhance the student’s abilities to participate in the educational process. Occupational therapists help individuals to do and engage in the specific activities that make up daily life. For children and youth in schools, occupational therapy works to ensure that a student can participate in the full breadth of school activities. Including paying attention in class, concentrating on tasks, appropriate posture, pencil grip, and classroom behavior.

Occupational therapists may be recommended for an individual student for reasons that might be affecting his or learning or behavior, such as motor skills, cognitive processing, visual or perceptual problems, mental health concerns, difficulties staying on task, disorganization, or inappropriate sensory responses. The occupational therapist accesses the child’s skills and other problems (including behavior), in addition to his or her visual, sensory, and physical capabilities. Vision Screening is an additional service offered by our Occupational Therapist and is conducted at school. Please contact The Learning Center for more information.

A Cognitive Developmental Program to strengthen cognitive abilities and decreases learning, emotional, and social challenges, to help students achieve their fullest potential. "It is a progressive system of physical, visual, auditory, vestibular, and cognitive exercises meant to strengthen existing neural connections and, more importantly, to create missing neural pathways which may inhibit one's ability to learn." (www.equippingminds.com)

Includes observation of a student in classroom setting (if appropriate), review of intake form, consultation with student/teacher/parents, formal & informal assessments to determine appropriate plan of care & goals.

For our current schedule of fees and information, please view TLC Fees and Information.

Subject Tutoring

Individual tutoring allows students to meet with a subject specific tutor.

For our current schedule of fees and information, please view TLC Fees and Information.

Parental Consent to Services & Commitment to Fees

Sessions NOT canceled within 48 hours will be invoiced at the rate of the full cost of the missed session. (Unless in the instance of a sudden illness or family emergency.) After two missed appointments without 48 hours notice, ECA reserves the right to fill your child’s appointment spot with another student from the waiting list.

Please make checks out to Eukarya Christian Academy.

Please inquire with your insurance company to see if reimbursement is an option.

Parents will be invoiced for services on a monthly basis.