Tutoring Intake (Minors)
Thank you for considering tutoring with Inspire Behavioral Learning, LLC! Please complete this initial intake form, and you'll receive a follow-up message. We look forward to working with you!
How Did You Hear About Us?
Please select all that apply.
*
510 Families
Activity Hero
Bay Area Kid Fun
Berkeley Parents Network
Craigslist
Google Search
Friend
Other
Tutoring Service Request
Please check all that apply. You may check more than one box per section.
Subject(s) Requested
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English Language Arts (ELA) (PreK-adults)
English as a Second Language (ESL) or English for Speakers of Other Languages (ESOL) (PreK-adults)
Mathematics (PreK-6th grade)
PreK-6th Grade Multiple Subjects
Executive Functioning
Location(s) Requested
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Online
Student's Home
Student's School
Library
Park
Other
1:1 or Small Group Requested
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1:1
Small Group (2-6 students)
Preferred Duration of Sessions
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1 hr per session
1.5 hrs per session
2 or more hrs per session
Preferred Frequency of Sessions
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1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
Available Tutoring Days & Times
*
Please note that Inspire's hours of operation are Mon-Fri 8:00 AM-7:30 PM & Sat 9:00 AM-6:30 PM.
Preferred Start Date
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-
Month
-
Day
Year
Date
Student Information
Student Name
*
First Name
Last Name
Student's Own Email Address (if applicable)
example@example.com
Student's Own Phone Number (if applicable)
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Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Grade
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Pre-K or TK
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
College
University
Not Enrolled in School
School
*
Parent/Guardian Information
Primary Parent or Guardian Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Parent or Guardian Name
First Name
Last Name
Email Address
example@example.com
Phone Number
-
Area Code
Phone Number
Brief Skills Assessment
Please write your child's greatest strengths and greatest needs that you'd like us to address in tutoring.
Greatest Strengths
*
Skills to Strengthen in Tutoring
*
Brief Preference Assessment
Please indicate a few of your child’s favorite items and activities that we have your permission to incorporate into lessons and to use as reinforcement. For items/activities your child does not prefer, please indicate N/A.
Preferred toys and games:
*
Preferred sports and physical play activities:
*
Preferred videos, shows, and movies:
*
Preferred books and authors:
*
Preferred music:
*
Other preferred items/activities:
Questions/Comments and Form Submission
Questions/Comments
Date of Submission
*
-
Month
-
Day
Year
Date
Submit
Thank You
You made it to the end! Thank you for completing Inspire's initial intake form. Please note that afternoons for tutoring in person are the quickest to fill and may not be available. Contact info@inspirebehavior.com if you have questions.
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