Services Information Form
Please complete the following form so we can best serve you.
Which services are you interested in today
Academic Tutoring (K-12)
Academic Tutoring (College Students)
College Application Assistance
Scholarship Search Assistance
IEP Advocacy (PK-12)
Accessibility or Disability Services Advocacy (College and beyond level)
Student Information
Student Name
First Name
Middle Name
Last Name
Preferred Name
Gender
Race
Hispanic/Latinx?
Yes
No
Age
Current educational level
Junior
Senior
Recent high school graduate
I have been out of high school for a while
I am looking to return to college and finish my degree
College graduate
Parent/Guardian Contact Information
Parent/Guardian Full Name
First Name
Last Name
Parent/Guardian Full Name
First Name
Last Name
Parent/Guardian Phone Number
Format: (000) 000-0000.
Parent/Guardian Phone Number
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Parent/Guardian Email
example@example.com
Student Information
Name
First Name
Middle Name
Last Name
Preferred Name
Gender
Race
Hispanic/Latinx?
Yes
No
Age
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Referral
Internet Search
Website
School
Emergency Contact
Emergency Contact Full Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Academic Information
K-12 School Name
Grade Level
College information
College or University
Classification (College freshman, junior, etc...)
What areas does your student need assistance in?
What subjects/areas is assistance needed in? Select all that apply.
Reading (K-5th)
Reading (6th-8th)
Reading (9-12)
Math (K-5th)
Math (6th-7th)
Algebra
Geometry
Science (K-5th)
Science (6th-8th)
High School Biology
High School Chemistry
High School Physics
Test prep
PSAT prep
ACT prep
SATP2
Study skills
Other
Is your student participating in remote learning ?
Yes
No
Please list the information for the courses your student is having challenges with
Teacher's name
First Name
Last Name
Teacher's website
Teacher's name
First Name
Last Name
Teacher's website
If there are additional teacher's then please list their names and class websites here
Please provide the teacher's full name and website if known
Which courses would you like assistance in?
Select all that apply.
Test prep
Study skills
General Chemistry 1
General Chemistry 2
Organic Chemistry 2
Organic Chemistry 2
Biochemistry
Algebra
Calculus
Other (please list below)
If you selected other, please list the course your looking for assistance in below.
Are you participating in remote learning?
Yes
No
Availability
What days and times can you have tutoring sessions?
What types of scholarships are you interested in pursuing?
What days and times can you meet for application assistance sessions?
What types of tutoring sessions are you open to?
In person
Virtual
Both
IEP Advocacy Services
Does your student have a learning disability or do you suspect your student has a learning disability?
Yes
No
Unsure
Please tell us what you would like for us to help you with.
Are you interested in our IEP Advocacy Services for you child?
Yes
No
Unsure if I need this
Does your student has a learning disability or you suspect your student has a learning disability?
Accessibility or Disability Advocacy Services
Are you interested in our Accessibility Advocacy Services?
Yes
No
Unsure if I need this
Do you have a learning disability or accessibility challenge or do you suspect that you have a learning disability or accessibility challenge that is impacting your performance?
Yes
No
Unsure
Are you having any challenges with getting your accommodations approved at your college or university? If so please list below.
Learning Goals
What are the major goals for your student's learning?
Please list any additional information you would like us to know about your student.
Please list any additional information you would like us to know.
How did you hear about us?
Referral
Internet Search
Website
School
Type a question
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