Dyslexia Screening Referral Form

Dyslexia Screening Referral Form — Form Fields

This education template includes 12 fields. Referral form for teachers and parents requesting student dyslexia screening. Free to customize and use on ZenBuild.

• Student Name (text, required)
• Date of Birth (text, required)
• Grade Level (text, required)
• School Name (text, required)
• Referring Person Name (text, required)
• Referral Source (dropdown selection, required) — options: Teacher, Parent, School Counselor, Pediatrician, Tutor, Self-Referral
• Referral Contact Email (email, required)
• Observed Difficulties (checkboxes, required) — options: Letter Reversals, Slow Reading, Poor Spelling, Difficulty Sounding Out Words, Avoids Reading, Poor Handwriting, Trouble Following Directions, Difficulty with Rhyming
• Duration of Concerns (dropdown selection, required) — options: Less Than 6 Months, 6-12 Months, 1-2 Years, 2+ Years
• Previous Screening or Testing (multiple choice, required) — options: Yes, No
• Describe Specific Concerns (long text, required)
• Work Samples or Previous Reports (file upload, optional)