Mindful Living Payment Form

Mindful Math Tutoring Form

Thank you so much for choosing and trusting me with your child to help build confidence, learn calming strategies, practice positive mindset, and succeed at mathematical concepts. Sessions are $50 for 45 minutes or $60 for an hour. (There is a discount for prepaying for a session package.) The first 5 minutes or so are spent centering with a mindfulness strategy to relax and focus. The remaining time is for working on the math concept. After each session, you will receive a summary via text or email. Please complete this form and submit payment via Venmo. (Contact me if you need an alternate payment form.) Contact me at any time with questions: 801-558-3020. Breathe in, breathe out, and smile!
What specific math content help does your child currently need?

Assist with math homework (child will bring homework problems to tutoring)Math Facts (addition, subtraction, multiplication, division)Fractions and DecimalsPlace Value (ordering and comparing numbers, rounding)Geometry (shape classification, angle measurement)Word/Story ProblemsChallenging Problem Solving MathOther
How often would you like your child to be tutored?

Once a weekTwice a weekThree times a weekOn an as-needed basis or alternate arrangement
Where would you prefer tutoring to take place?

At child's homeAt a local libraryOnline
How would you like your child's tutoring session summary sent?

EmailTextOther
Please select which package you prefer. Once you have completed the form, you can submit payment via Venmo - @Chrystine-Gonzalez

Single 45 min. session ($50)Single 60 min. session ($60)6 sessions 45 min. each ($270)6 sessions 60 min. each ($330)
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Phone Number
Email
example@example.com
Preferred form of communication:

PhoneTextEmailAny type is fine
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of tutoring the child will need.

I understand that in order to be successful, it is vital to communicate any concerns or ask any questions in a timely manner.

If I need to cancel an appointment for any reason (except for an immediate emergency), I will give 24 hours notice or be charged for the scheduled session.
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Mindful Math Tutoring Form