Irlen Syndrome

Let’s work together.

If you are local to the Northern Virginia area and would like to have your child screened for Irlen Syndrome, then please fill out the following form and I will get back to you to schedule a time and location for screening.

Special Note: Before completing the form, please make sure you reviewed the Irlen Syndrome Website to verify that you believe this may be an aspect of your child’s educational journey that needs to be explored.

Name of Parent

First Name

Last Name

Name of Child

First Name

Last Name

Phone

(###)

###

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Details:

Please tell me about your child and their experiences/difficulties thus far. Please include your child's age.

Additional Information:

Anything else you would like to share?

Irlen Syndrome

Let’s work together.

Warrenton, VA