Student Intake Form

Student Name:

First / Last NameNickname

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Numbers:

HomeCell

Email:

Date of Birth:

Place of Birth:

Citizenship (if not US):

Current School:

Guidance Counselor:

Previous Schools Attended (Dates and Grade):

Expected year of graduation:

Current GPA (please email or send me copies of all transcripts since 9th grade):

All standardized test results and dates. Please break down the total into sections.

ACT: SAT: SAT subject tests:

AP Classes and test results:

How would you describe your child’s ethnic background?

If you child plays sports at a competitive level, please describe.

If your child does music, visual art or theater at a significant level, please describe.

Summer Program/Internships/PT Jobs

Parent Information

Student lives with (Check all that apply):

Check all that apply:

If step-parents are in the picture, please add their information too.

Siblings: (Name, Age, and School)

Which parental adults should the consultant contact with updates etc.?

Which parental adults will be contributing financially to college for the student?

Father's Info:

Name:

First NameLast Name

Country of Birth:

Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

HomeCell

Email

Occupation:

Employer:

College Attended/Degree:

Graduate School Attended/Degree:

Mother's Info:

Name:

First NameLast Name

Country of Birth:

Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

HomeCell

Email

Occupation:

Employer:

College Attended/Degree:

Graduate School Attended/Degree:

Paying for college

How will college be paid for and by whom? Savings? Current income? Student loans?

Parent loans? Grandparents?

How much do you have saved specifically for this student’s undergraduate education? (Don’t include retirement savings, savings allocated for sibling’s college education, or home equity.)

How much per year can you afford to pay out of your household income for this student’s undergraduate education?

Household income range (adjusted gross income from most recent tax return):

Will you be applying for need-based financial aid, which is determined largely by the household AGI for the tax year in which the student becomes a high school senior. If yes, what is your Expected Family Contribution/EFC? (You can determine this at collegeboard.com using your most recent tax return or your estimated AGI. EFC calculator: https://bigfuture.collegeboard.org/pay-for- college/paying-your-share/expected- family-contribution- calculator.

Please calculate both IM and FM bottom lines. Let me know if you would like help using the calculator. Note that several well-known colleges, including the Ivies, MIT, Stanford, Amherst, Williams, Wesleyan and Swarthmore, give financial aid solely on the basis of need. (Put another way, if your student is brilliant but you have no “need” –- your EFC is higher than the annual cost of attendance –- you will still not be eligible for financial aid at this group of colleges.)

However, very many other colleges at all levels award financial aid unrelated to need, often called “merit aid”. Merit aid is awarded for academics, test scores, community service, athletics, artistic talent (music, visual art, drama, dance), ethnic and geographic diversity. Note also that students who get Bs and Cs can get merit aid at the right college.

Do you want your student to apply to colleges that give merit aid?

Both parents should fill out this part of the questionnaire separately

PARENT ONE

What role will religion play in choosing a college?

What role will politics play in choosing a college?

Are there areas of the country you want to focus on for the college search?

Are there areas of the country you have ruled out for the college search?

Are you interested in considering education outside the USA (Canada, UK, Ireland, etc.)?

Are there particular colleges you would like you child to consider and why?

Are there specific colleges you do NOT want your child to apply to and why?

Are there any “deal-breakers” as far as you are concerned, in choosing a college? (e.g. It must be in driving distance, public vs private.)

Describe your child – academics, social, interests, and temperament.

In addition to the parents’ alma maters, are there other colleges where your child may be considered a legacy?

What do you hope your child gets out of his/her college experience?

What kind of college do you think he/she would thrive in?

What are your own biggest concerns for the next few years of transition?

What do you hope to gain from working with me?

Challenges

Have there been events, circumstances, or experiences that have had a major impact in the last few years? (moving, accident, divorce, death, birth, etc.)

Does your child have particular challenges—learning differences, psychological/emotional?

Does your child have an IEP and/or accommodations in school or for testing? Please send me any documentation, neuro-psych or psycho-educational testing reports

Is your child is on any type of medication or has health issues I should be aware of:

Is there anything else you would like to tell me?