Initial Consultation or Tutoring Registration Form

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Referral InformationSo glad you found me! How did you find out about Amy Janjgava's Tutoring and Decode Learning Hub?
Website
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Did someone specifically refer you?Please let me know who to THANK for sharing about my services.
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Student's Full Name* This field is required.
First Name
Middle Name
Last Name
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Student's Preferred Name* This field is required.Please
e.g. nickname
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Mailing Address* This field is required.This allows me to mail any materials, possible cards or invoice/forms/etc.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Philippines
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Date of Birth* This field is required.
Date
Year
Month
Day
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My child is blanks years and blank months old.
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Gender/Pronouns* This field is required.
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Interests/Talents/Sports:* This field is required.
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Small
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Ok
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Allergies/ Medications/ Medical Conditions you would like me to be aware of:* This field is required.
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Parent/Guardian #1 Name: * This field is required.
First Name
Last Name
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Parent/Guardian #1 Relationship to the Child:* This field is required.
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Parent/Guardian #1 Email:* This field is required.
example@example.com
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Parent/Guardian #1 Phone Number:* This field is required.
Area Code
Phone Number
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Parent/Guardian #1 Place of Employment/Profession: * This field is required.
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Parent/Guardian #2 Name:
First Name
Last Name
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Parent/Guardian #2 Relationship to the Child:
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Parent/Guardian #2 E-mail
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Parent/Guardian #2 Phone Number:
Area Code
Phone Number
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Parent/Guardian #2 Place of Employment/Profession:
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School setting* This field is required.Please select one of the following
Please Select
Please Select
Public School
Private School
Traditional Homeschool
Classical Homeschool
Charlotte Mason Homeschool
Eclectic Homeschool
Relaxed Homeschool
Unschooling
World Schooling
Other Learning Setting
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Current Grade Level (2021-2022)* This field is required.
Please Select
Please Select
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
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Has your child ever been retained?* This field is required.
YESNO
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If your child has been retained, please indicated what grade level: blanks
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Learning Disability/Related Disorder (if applicable)* This field is required.
ADHD
Other Writing Disability
Specific Learning Disability
Other Math Disability
Dyslexia
Other Reading Disability
Dysgraphia
Other (explain below)
N/A
Other
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When and where was the disability diagnosed?Please attach any/all educational testing reports that support the identification indicated above if you are seeking eligibility or compatibility for specific services.
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Tell me about your student's previous tutoring experiencesEx. Public education, private institution, group or individual, delivery of program/tutoring, number of days, time allotted per session, positive aspects you appreciated, areas you felt were lacking and seeking for future tutor/therapist.
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Please share any programs, interventions, or materials the student has had exposure to or completed. How did the student respond to the intervention? Positive aspects? Areas of Difficulty? Completion? If not completed, what cause the early termination?
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What service(s) are you interested in learning more about?* This field is required.Please share any specific areas of concern or skills that you are seeking tutoring/therapy/intervention for that you would like me to address
Early Reading Enrichment (PreK-Kindergarten)
Reading Automaticity/Fluency (1st-2nd)
Early Reading Intervention/Support (K-2nd)
Reading Comprehension/Vocabulary (K-2nd)
Handwriting & Spelling Instruction (K-2nd)
Dyslexia Therapy (4 days a week)
Other/Not Sure
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Format of Instruction you are seeking?* This field is required.
Face-to-Face (Morning/Daytime)
Online (Morning/Daytime)
Face-to-Face (After School Hours)
Online (After School Hours)
Hybrid (Both In-Person & Online)
Either In-Person or Online
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Please select ALL possible days/times your child is available for tutoring.* This field is required.* The below options are CST and it will help with determining availability. The times below do NOT suggest that each time slot is currently available.
9:00am CST
Mondays
10:30am CST
Tuesdays
1:30pm CST
Wednesdays
4:00pm CST
Thursdays
5:00pm CST
Fridays
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Testing Reports/Dyslexia/504/Special Education IEPsFeel free to add any testing reports, dyslexia diagnosis/identification, 504/SPED IEP paperwork that you would like me to review or incorporate into sessions.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
File should be in pdf, doc/docx format.
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Do you have any additional information, comments, or questions you would like me to know about?
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Please Indicate You are Not a Robot* This field is required.Check the box.
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ID
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