APPOINTMENT FORM

* Fields marked as such are mandatory.

1. Name and surname of the child's parents/legal representative

2. Phone

3. Email

4. Name and surname of the child

5. Date of birth of the child

6. Previous examinations already completed (multiple options can be picked)

PPP STEP Another counceling center No examination

7. The child is currently visiting

8. Name of the school establishment

9. Class

10. Difficulties

11. A more detailed description of the difficulties

12. I am asking for (multiple options can be picked)

Examination Consultation Course

13. Kind of examination (multiple options can be picked)

Comprehensive/individual education School readiness Premature school maturity Special pedagogical Psychological Adaptation to entrance exams Professional orientation Homeschooling

14. Kind of consultation (multiple options can be picked)

Pedagogical Psychological Individual therapy Family therapy

15. Course (multiple options can be picked)

Preparatory course for children before school Graphomotor course Social skills training Reeaducation Development program for the support of attention and memory

Receipt of the appointment form will be acknowledged by the employee within 3 working days.

WHERE CAN YOU FIND US?

Pavlisova 2246
272 01 Kladno

DO YOU HAVE ANY QUESTIONS?

+420 770 178 965
+420 602 590 000
vds@ppporadna.cz

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