ABA Academic Tutoring Interest Form

Academic Tutoring Interest Form

Applied Behavioral Approaches
Parent/Guardian Information
Name*

First NameLast Name
Relationship*
Mother, Father, Grandparent, etc.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Information
Name*

First NameLast Name
Gender*

FemaleMale
Birthdate*

MonthDayYear
Date
Which grade is your son or daughter in?*

Pre-KFirstKindergartenSecond
Does your child have an IEP or 504 Pllan?*

YesNo
Does your child have any special needs that require 1:1 support?*

YesNo
Does your child have a clinical diagnosis(es) of any of the following? (Check all that apply)*

NoneAD/HDAutismDown SyndromeIntellectual DisabilityDyslexiaGlobal Developmental Delay/Significant Developmental DelayLanguage DisorderOther
What are your child's toilet training needs?*

Not toilet-trained; currently wearing diapers.Successfully goes to the bathroom with assistance if verbally reminded; if not accidents occur.Can independently complete all tasks surrounding going to the bathroom, but lacks the skill to vocalize the need to use the restroom.Is completely toilet trained, can identify when they need to “go”, will notify an adult/caregiver of this and will use the toilet independently without assistance.
School Attending or Zoned For*
If your child has never attended any type of schooling, put N/A. If home-schooled please indicated "Homeschool".
Class Type & Grade*
General education Pre-K, Special education Pre-K, Gen Ed 1st grade, etc.If your child has never attended any type of schooling, put N/A.
Tutoring Preferences
Tutoring Focus Area(s) Desired*

MathReadingScienceSocial Studies
Hours of attendance desired (clinic hours are 9:00 am to 2:00 pm)*

Full dayHalf-day morning (9:00 a.m. - 11:00 a.m.)Half-day afternoon (12:00 p.m. - 2:00 p.m.)Other
Days of the week desired*

MondayTuesdayWednesdayThursdayFriday
Please provide any additional information here: Learning strengths and challenges, current medications, allergies, therapies, or chronic health concerns.
Please verify that you are human*
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Academic Tutoring Interest Form

Parent/Guardian Information

Child Information

Tutoring Preferences