Scholar Intake Form

Scholar Intake Form

EXCELLENCE is our standard. SUCCESS is our GOAL.
Parent / Guardian Information

Please provide your contact details so we can reach you regarding your scholar.
Parent/Guardian Full Name*

First NameLast Name
Relationship to Student*
Preferred Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Communication*

PhoneEmailText
Student Information

Tell us about your scholar so we can better understand their academic journey.
Student Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Age*
Gender
Ethnicity
Primary Language Spoken at Home
Grade Level*
School Name*
School District
Teacher(s) Name(s) (if applicable)
Academic History & Performance
Which subject(s) is your child seeking support in?

ReadingMathWritingScienceTest PrepHomework SupportStudy SkillsOther
How would you describe your child’s current academic performance?*

Above Grade LevelOn Grade LevelBelow Grade Level
Has your child received academic interventions in the past?

YesNo
If yes, please describe (IEP, 504 Plan, tutoring, RTI, etc.)
Learning Style & Behavior
Does your child struggle with any of the following?

Focus / AttentionComprehensionRetentionTest AnxietyConfidenceTime ManagementOrganizationNone
How does your child learn best?

VisualAuditoryHands-OnCombination
How does your child typically respond to academic challenges?

Becomes frustratedAvoids workAsks for helpPersists independently
Any behavioral, emotional, or learning concerns we should be aware of?
Goals & Expectations
What are your short-term academic goals for your child?*
What are your long-term academic goals for your child?*
What prompted you to seek services at BJ’s Brain Booster Academy at this time?*
Scheduling & Services
Preferred days for sessions

MondayTuesdayWednesdayThursdayFridaySaturday
Preferred time of day

MorningAfternoonEvening
Desired service type

One-on-One TutoringSmall Group SessionsLearning Lounge / Study HallTest PrepAcademic Coaching
Health & Learning Considerations
Does your child have any medical conditions, allergies, or accommodations we should be aware of?
Are there any safety or emergency considerations for your child?
Additional Information
Is there anything else you would like our Academic Advisor to know about your child?
Consent & Acknowledgment
Acknowledgment*

I understand that BJ’s Brain Booster Academy provides academic support services and does not replace formal school instruction.
Consent*

I consent to an academic assessment and personalized learning plan for my child for the use of academic coaching and tutoring services at BJ's Brain Booster Academy.
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Scholar Intake Form

Parent / Guardian Information

Student Information

Academic History & Performance

Learning Style & Behavior

Goals & Expectations

Scheduling & Services

Health & Learning Considerations

Additional Information

Consent & Acknowledgment