Tutoring Intake (Adults)
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.
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Craigslist
Google Search
Friend
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)
English as a Second Language (ESL) or English for Speakers of Other Languages (ESOL)
Executive Functioning
Location(s) Requested
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Online
Student's Home
Student's School
Library
Park
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
1:1 or Small Group Requested
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1:1
Small Group (2-6 students)
Available Tutoring Days & Times (e.g., "MWF 3:00-6:00 PM")
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
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
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-
Area Code
Phone Number
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name (If not enrolled, write N/A)
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Highest Grade or Highest Degree Completed
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Language(s) Spoken Fluently
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Translator/Assistant Information
If a translator or assistant is helping the student complete this form or is completing this form for the student, please indicate that person's information below.
Translator/Assistant Name
First Name
Last Name
Email Address
example@example.com
Phone Number
-
Area Code
Phone Number
Brief Skills Assessment
Please write your greatest strengths and greatest needs that you'd like us to address in tutoring.
Greatest Strengths
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Skills to Strengthen in Tutoring
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Brief Preference Assessment
Please indicate your hobbies and interests that we have your permission to incorporate into lessons. For items/activities you do not prefer, please indicate N/A.
Most preferred hobbies and interests
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Preferred sports and physical activities
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Preferred videos, shows, and movies to watch
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Preferred books, authors, and websites to read
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Preferred music
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Other preferred items/activities
Questions/Comments and Form Submission
Questions/Comments
Date of Submission
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-
Month
-
Day
Year
Date
Submit
Thank You
You made it to the end! Thank you for completing Inspire's initial intake form. We'll be in touch. Contact info@inspirebehavior.com if you have questions.
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