Learning Through Play Questionnaire

Learning Through Play Questionnaire

Thank you for taking the time to fill out this information concerning your child. Your answers will only be used to help me get to know your child as a learner. Please complete this form prior to scheduling.
Parent/Guardian Information

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child Information

First NameLast Name
Location: (Preference Local Library or Park) Spartanburg,SC and surrounding areas

Location

County

CityState / Province

Comments
Age
List the weakness(es) your child has in academic work.
What is/are the reason(s) you would like your child to be a part of Learning Through Play? You can choose more than one*

Other
List any special interests your child has(ie characters, activities, etc). This can assist in finding structrured activites that appeal to your child.
Preferred day/time? * Weekends and Limited Weekday Availability at this time unless discussed otherwise.
I am very delighted to have the opportunity to assist your child with the skills required in the school setting through play! The following are some guidelines to help our sessions run more effectively. Please keep this copy for your records.

Sessions will be held at your local library or park at the mutually agreed upon time/day(s).

1 hour sessions will be $25 , for 30 minute sessions $15. 30 minute sessions are recommended but not required for under 5 years of age due to their limitations with focus. A $5 deposit is required to schedule that will go toward the session. The complete payment for tutoring is due at each session. PLEASE CONTACT ME VIA EMAIL: Learningthroughplaytutoring@gmail.com TO VERIFY IF THE TIME IS AVAILABLE BEFORE SENDING YOUR DEPOSIT. Payments via Venmo, Zelle, or Paypal: SRCloud216. A invoice will be provided via email/text.

I will keep an ongoing summary/report of what your child and I have worked on. Our first session would consists of observing /evaluating current skills.

If at any time you have questions, concerns or need additional information, don't hesitate when it comes to communication.

****Disclaimer****

I am a Certified Occupational Therapy Assistant (COTA) with experience supporting children in the areas of fine motor development, handwriting readiness, visual-motor integration, sensory-based activities, self-care skills, and school readiness.

The services I provide through this program are educational, developmental, and skill-building in nature and are not occupational therapy services. Participation in this program does not establish an occupational therapy provider–patient relationship, and these services are not intended to evaluate, diagnose, treat, or replace occupational therapy or any other medical or therapeutic services.

Please consult a licensed occupational therapist, speech language pathologist, your doctor, or another qualified healthcare professional regarding your child’s health. I can not diagnose or provide services outside my scope of practice.

**About me: My name is Shaquita Cloud, COTA/L . I liscensed certified pediatric occupational therapy assistant since 2020. I started my career in early intervention to my current position as a school based COTA. Beginner ASL skills ! What is a better way to learn than through play? My goal is to make learning fun!
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