Name: | DOB: | MRN: | PCP:

Luke Waites Center for Dyslexia and Learning Disorders

Four steps to submit application for evaluation of child

Step 1

Request authorization to receive access to the easy-to-use secure online application.

Step 2

You will then receive an authorization (also called a proxy) activation link within 2-3 business days. This will be your access to the easy-to-use online tool where you will be able to submit your child’s application.

Step 3

Once Step 2 is complete, you will receive the online application link within 2-3 business days. Please be prepared to provide copies of prior testing / evaluation, any relevant school documentation, and a copy of your identification (driver’s license, passport, etc.).

Complete the application in its entirety. Submit application and documentation.

Step 4

After you submit the application, the Application Committee will review it, and will contact you within 3 weeks.

Application Request Form – Step One

Thank you for your interest in the Luke Waites Center for Dyslexia and Learning Disorders.

You are going to be given access to an easy-to-use online tool to securely submit your child's information.  Before you start, please be aware that:

• Access can only be given to a parent or legal guardian.
• Your child must be:
• a Texas resident
• between the ages of 5 and 14 years
• a proficient English speaker 		✓
✓
✓

If you are a parent or a legal guardian who would like to receive an application to the Center for Dyslexia, please complete the following information.

The child’s biological/adoptive parents are:
With whom does the child primarily reside? (You can check more than one box)

Parent 1 / Guardian / Legally Responsible Person Information
 

Date of birth of the parent or legal guardian.

Sex
Do you have an existing MyChart account with Scottish Rite?
Parent 2 / Guardian / Legally Responsible Person Information
 

Date of birth of the parent or legal guardian.

Sex
Do you have an existing MyChart account with Scottish Rite?
Child's Information
 
Sex
Parent 1 Relationship to Child
Parent 2 Relationship to Child
Legal guardian for this child is?

 
Additional Child’s Information

Only enter information here if you’d like to have an additional child evaluated.


 
Sex
Parent 1 Relationship to Child
Parent 2 Relationship to Child
Legal guardian for this child is?

 
Certification

I certify that I am the patient or legally authorized representative of the patient. By signing this form, I acknowledge that I have read and understand this myChart Request Form and I agree to its terms and conditions. I hereby request access to my child and/or children’s online health record.

Certification


If you have any questions, please contact the Center for Dyslexia at 214-559-7815.