If you're interested in our educational services, please fill out the following Academic Intake Form. Academic Intake Form Child's Name(Required) First Last Child's Date of Birth(Required) Month Day Year Family concern/Reason for referral (ex: new dyslexia diagnosis, change in grades):(Required)Has your child ever been retained/held back a grade?(Required) Yes No Please list any diagnosed learning differences: (ex: ADHD, slow processing speed, specific learning disability, etc)(Required)Does your child currently have an IEP or 504 plan?(Required) Yes No If your child does have a 504 or IEP (or is in the process of receiving one), upload the most recent and/or their ETR assessment. Drop files here or Select files Max. file size: 195 MB. Please describe your child’s learning style: (ex: visual learner, gets bored easily, studies with flashcards, works best in a group, etc)(Required)Please describe your child’s personality: (ex: easily frustrated, compliant, requires frequent breaks, attentive, avoidant, etc)(Required)What subjects do you think your child needs the most support with? Please check all that apply.(Required) ELA Math Science Social Studies Select AllIs there anything else we should know about your child?(Required)If not, just write N/A for not applicableHow often would you like your child to be tutored, and where would you like this to take place?(Required)How did you hear of us?(Required) Online search Social media Brochure, flier, business card, or other printed media Recommended by friend or family member Referred by physician or other healthcare provider Recommended by a school or teacher Online ad Other Parent Phone Number(Required)What's the best number to reach you?Parent Email Address(Required) Parent Electronic Signature First Last By providing this electronic signature, I attest that this information is complete and true to the best of my knowledge. 72937Δ
