Free Learning Consultation Form

Learning Consultation Registration Form

Includes Free 30-minute Learning Consultation
Name*

First NameLast Name
Parent or Guardian (if under 18)*

First NameLast Name
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
Date
Grade Level*
How did you find me?*

Shore Website/Management OfficeFriend/Family MemberFacebookInstagramGoogleLearning Aid Ohio Provider ListACE MarketplaceCommunity NewspaperOther
What is your time zone?*

Eastern TimeCentral TimePacific TimeOther
Type of schooling?*

HomeschoolPrivate SchoolPublic SchoolVirtual Public School
Could you please provide a detailed list of the specific reading, math, and/or executive function challenges your child has been experiencing?.*
In terms of your child's reading, math, and/or executive function journey, what are some of the key goals you have in mind for their improvement and growth?*
Could you share some insight into your child's emotional relationship with reading, math, and/or executive function skills? How do they generally perceive and approach activities that are challenging?*
Which tutoring session length works best with your son's or daughter's schedule?*

30 minutes60 minutes
Are you interested in group lessons (2-3 children with similar challenges)?*

YesNoMaybe
Is there anything else you’d like me to know?*
I’d like to stay in touch with you! I promise to only send you emails or text messages regarding being a student of my class or information which will have value to you as a student or parent. By providing your email address and telephone number, you agree to receive emails and text messages from Engaged Minds Educational Services.*

Yes, I agree to be added to the email list and receive text messages. I understand I can opt out at any time.No, I do not want to be added to the email list or receive text messages.
Would you like to schedule your FREE 30-minute learning consultation?*

Yes - Please choose a date and time below.No - I'll be in touch by email in the next 72 hours.
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Learning Consultation Registration Form