New Student Details:
Student Name
*
First Name
Last Name
Student Photo
*
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Try to find a photo that captures their personality!
Cancel
of
School
*
FIRST Day of School for current or upcoming school year:
-
Month
-
Day
Year
Date
LAST Day of School for current or upcoming school year:
-
Month
-
Day
Year
Date
School Calendar Link:
This is for our scheduling purposes. Please either link a calendar or upload a calendar document.
School Calendar File
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Cancel
of
Current Grade
*
Date of Birth
*
Mother/Father/Guardian Name
*
First Name
Last Name
Mother/Father/Guardian Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
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Poland
Portugal
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Romania
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Country
Contact Phone Number
*
-
Area Code
Phone Number
Contact E-mail
*
Preferred method of communication/contact:
*
Phone
Email
Text
Other
For future scheduling confirmations, preferred method:
*
Email
Text
Other
How did you hear about us?
*
Please Select
Friend
Psychologist
School Personnel
Online Search
Other
Food Allergies
*
If none, state N/A.
Is your child allergic to dogs?
*
If none, state N/A.
Tell us about your child:
*
What makes your child unique:
*
Diagnoses:
*
Dyslexia
Dysgraphia
Dyscalculia
ADHD
Autism
Speech Language Articulation
Expressive/Receptive Language Disorder
Executive Functioning Disorder
Written Expression Disorder
None of the Above
Other
Diagnosis Explanation
*
Is your child aware of their diagnosis?
*
Yes
No
No, but we plan to tell him/her.
Other
Current Grades in School: how is your child performing?
*
Has your child had tutoring elsewhere? Was it beneficial? If possible, please list programs used.
*
Student Interest/Hobbies :
*
What are your academic goals/hopes for your child?
*
What are your social/emotional goals/hopes for your child?
*
Are we able to take and share photos of your child on our Facebook/social media outlets?
*
Yes
No
Please list at least one emergency contact:
*
Full Name
Address
Contact Number
1
2
Testing/School Documents
Browse Files
Any psychological testing reports, IEPs, etc.
Cancel
of
Testing Documents Password
Please List all passwords and what document they correlate to. Thank you!
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