I am interested in information for the following services: Special Education Literacy Clinic Educational Therapy L.A. Times Reading Clinic Psychoeducational Testing Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Name of Student * Grade Level * Gender * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Address Street Address * City * Zip * Parent(s)/Guardian(s) Name * Email Address * Phone Number * Name of School Attending * How did you find out about the Teaching, Learning & Counseling Consortium? * Has the student had special help such as tutoring, special classes, etc? Yes No Would you like to be contacted by the Mitchell Family Counseling Clinic for information about family/individual counseling? Yes No Would you like to be contacted by a representative of the Family Focus Resource Center for more information? Yes No Leave this field blank
