Tutor Intake Form

Pencils Crayons and Markers LLC Intake Form

Request a consultation by filling out the form below. Please allow up to 24-48 hours for a response.
PhonicsSight Words/FluencyReading ComprehensionReading Comprehension StrategiesAdditional areas of focus are listed in the comment section below.
Sentence StructureWriting a ParagraphPenmanshipAdditional areas of focus are listed in the comment section below.
Number Sense, Counting StrategiesPlace Value/Word ProblemsAddition/SubtractionRelated FactsMultiplication/Division/FractionsAdditional areas of focus are listed in the comment section below.
Sessions per week of interest:*
Tutoring Session ($40.00/Hour/Self-Pay)Tutoring Session ($45.00/Hour/Step-Up for Students Scholarship)Free Consultation
Please note that there is a $25.00 deposit/materials/supplies fee upon registration if you choose our services.*
Assessment Scores Needed: Please request a copy of your child's most recent Instructional Planning Student Report for STAR Reading and STAR Math. The Instructional Planning - Student Report provides a list of recommended skills for individualized instruction in class and tutoring based on your child's academic activity since the 1st STAR Reading and STAR Math Assessments. *
Additional Info: Please give further detail about your child's academic needs, any possible learning disabilities, academic strengths, academic concerns, and/or questions and concerns:
Personal & Contact Information

Please make sure all information is accurate
Student's Name*

First NameLast Name
Birth Date

MonthDayYear
Student's Grade*
Gender
Parent's Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Should be Empty:

Pencils Crayons and Markers LLC Intake Form

Personal & Contact Information