INTAKE FORM

TUTORING
INTAKE FORM
StepUp for students
Name
Subjects
Address
Phone
Student Name
Agegrade level
Duration One Hour $85.00
Type Agree
Starting Date

MonthDayYear
Date
Learning goals
How many hours per week can the student allocate to homework
How does the student primarily learn and retain information? Auditory Logical/Mathematical
How does the student typically respond to tests and exams?
Any learning disabilities or special needs
How does the student prefer to receive feedback and guidance during tutoring sessions
Notes
Anything the tutor should know
Client Signature

Clear
Tutor Signature

Clear
Should be Empty: