Clone of Strategies for Learning Intake Form

Strategies for Learning: Summer Reading Intensive 2026

Carefully review our policies & procedures at the end of the forms. Thank you.
Student Information
Full Name:*

First NameLast Name
Goes by:
Gender:*
Date of Birth:*

MonthDayYear
Date
Grade Level (Fall 2026):*
School Name (Fall 2026)*
Summer Reading Intensive Information
Which Summer Reading Intensive are you registering for?*

2-week Intensive (10 sessions) $17004-week Intensive (20 sessions) $3120
Select your preference for session settings. (select all that apply):*

VirtualIn-person at the SfL learning clinic in OaklandPrioritize the strongest and best Clinician match, whether virtual or in-person
What time of day is the student available for sessions? (Any flexibility is greatly appreciated and will help us find the strongest Clinician-student match)*
What weeks during summer is the student available for the intensive? *
How did you hear about Strategies for Learning?*

ReferralGoogle SearchBerkeley Parent NetworkOther
If you were referred, who made the referral?*
Summary of Concerns
What do you see as the student's academic or learning needs?*
Describe the student’s strengths, special interests, or hobbies:*
Describe the student's mood, behavior, or emotional factors that may impact learning.*
To the best of your knowledge, is the student’s skill level below, at, or above grade level in each area?
Critical Thinking*

BelowAtAbove
Handwriting*

BelowAtAbove
Listening Comprehension*

BelowAtAbove
Mathematical Calculation*

BelowAtAbove
Mathematical Reasoning*

BelowAtAbove
Oral Expression*

BelowAtAbove
Reading Accuracy*

BelowAtAbove
Reading Comprehension*

BelowAtAbove
Spelling*

BelowAtAbove
Written Expression*

BelowAtAbove
Has the student received special education services?*

YesNo
If Yes, please describe the services.
Has the student received assessment in the last 2 years?*

YesNo
If Yes, please describe the assessments.
Which hand does the student use for writing?*
Which hand does the student use for other activities?*
What languages are spoken at home?*
Describe the history of learning difficulties/disabilities in any of the student’s blood relatives, if applicable:
Medical History
Please list any allergies:
Please list any medications taken on a regular basis (if applicable):
Does the student have any difficulty with vision (e.g. blinks, has headaches, squints, lose place when reading, holds books close, etc.)?*

YesNo
If yes, please describe:
Does the student have any difficulty hearing (e.g. ask "What?", appear inattentive, follow directions poorly, etc.)?*

YesNo
If yes, please describe:
Parent/Guardian Information

If multiple parents or guardians are involved with a student, we kindly ask each of you to provide the information below and attend the intake and any future consultations. If you are 18 years or older, please include the contact information of the person financially responsible for the services.
Relationship Status:*

Married/PartneredSingleDivorced/SeparatedOther
Parent/Guardian 1:*

First NameLast Name
Occupation:*
Employer*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone:*

Area CodePhone Number
Home Phone (if applicable):

Area CodePhone Number
Work Phone (if applicable):

Area CodePhone Number
E-mail:*
Parent/Guardian 2:

First NameLast Name
Occupation:
Employer:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone:

Area CodePhone Number
Home Phone (if applicable):

Area CodePhone Number
Cell Phone (if applicable):

Area CodePhone Number
E-mail:
Emergency Information

In case of an emergency, if the contacts listed under "Parents/Guardians" cannot be reached, please contact the individuals named below in the order provided.
Contact 1:*

First NameLast Name
Relationship to Student*
Phone Number*

Area CodePhone Number
Contact 2:*

First NameLast Name
Relationship to Student*
Phone Number*

Area CodePhone Number
Informed Consent
I consent to participate in educational services with Strategies For Learning, Inc. I understand that per Strategies For Learning, Inc. policy, all information, communications, observations, and opinions derived from this service will be kept confidential within the organization, but may be shared among professionals to provide the highest quality service.

I understand that educational therapy and other educational services provided by Strategies for Learning, Inc. cannot be guaranteed to produce a specific outcome or result, including, but not limited to exam(s) scores of any kind or admission to a particular school or program. My E-Signature below indicates that I have read and agree to the policies and information contained on this form.
Name of Parent/Guardian*
Relationship to student:*
E-Signature of parent/guardian*

Clear
Today's Date:*

MonthDayYear
Policies and Procedures

In agreeing to our policies and procedures, you are partnering with us in not only in service of the student, but in service of all our SfL families. Please carefully review each section and sign.
Fees and Billing

1. In order to secure your summer intensive slot, you will need to make a 50% deposit of the total amount of the summer intensive. The remaining amount is due 1 week before the start of the session. Payments can be made using our online payment portal.

2. For any services in addition to the summer intensive package, including ongoing fall support, our regular hourly rate of $165-175/hr will be applied. You will receive an invoice at the end of the month for all the services for that month. Full payment is due by the 15th of the following month.
Sessions

1. Sessions are conducted virtually, at our Oakland clinic, or at any other location agreed upon in advance with Strategies for Learning.

2. As we create a schedule for the student, we take into account the best Clinician match based on his/her needs, the clinician’s availability, and your family’s preferred schedule. SFL cannot guarantee a specific day or time until your schedule is confirmed.

3. Sessions will begin promptly as scheduled. If the student and parent/guardian are not present at the scheduled time, your Clinician will wait 15 minutes for them to arrive. After this waiting period, the session will be forfeited and you will be responsible for the payment for this session.

4. The relationship the student develops with his/her clinician is a key factor in his/her readiness to learn. The addition of a family member into the student's session can dramatically affect his/her performance. Regular parent observations are not permitted during sessions. If you would like to observe a sessions, you must schedule an appointment in advance.

5. Sessions or meetings held outside the SfL clinic within a 5-mile radius will incur a $10 travel fee per trip, in addition to the clinician’s hourly rate. For locations beyond 5 miles, travel time will be billed at the clinician’s hourly rate, prorated in 5-minute increments. Fees are subject to change with prior notice.

6. We work hard and invest time and resources in locating and selecting Clinicians. As a part of our agreements, all Clinicians agree that they will not accept direct employment from any of our clients during, or for two years after, the Clinician works for Strategies for Learning, Inc. As our client, you also are required to agree not to enter into a direct contract with our clinician during the same period of time.

7. We reserve the right to decline or terminate service; any sums you have paid in advance that have not been applied to services rendered shall be refunded to you upon such termination.
Progress Report

At the conclusion of the summer intensive, your Strategies for Learning clinician will prepare a written progress report and reach out to schedule a 30-minute parent meeting.

Together, the report and meeting will review:

The skills and strategies taught to address your child’s specific areas of focus
Observable growth and progress made during the summer intensive
Ongoing or emerging areas of challenge
Key recommendations to support your child during the upcoming school year
Communication With Your Clinician

1. Previous assessments are valuable in understanding the student needs. We encourage you to share recent school report cards, informal assessments, and psychoeducational or neuropsychological evaluations before the intake appointment.

2. You may contact your clinician directly or reach out to our Operations Manager for any scheduling issues or changes. Contact information will be provided upon the start of services.

3. Clinicians may reserve a few minutes before or after certain sessions to briefly address questions or concerns. However, frequent or extended phone calls or emails exceeding 10 minutes will be billed at the clinician’s hourly rate.

4. In addition to educational therapy, SfL offers related services such as educational consulting, advocacy, case management, and assessment services. These services are available upon request and billed at the clinician’s hourly rate.

5. By providing your mobile phone number, you consent to receive text messages from Strategies for Learning for administrative purposes, including invoices, payment reminders, scheduling updates, and appointment reminders. Text messages will not be used to discuss sensitive student information. Standard message and data rates may apply.
Cancellations and Make-up Sessions

1. Sessions cancelled due to illness may be made up only if the Clinician is notified at least 48 hours in advance, excluding weekends and holidays. Cancellations or no-shows with less than 48 hours’ notice are not eligible for make-up sessions.

2. If a Clinician needs to cancel a session due to illness or other unforeseen circumstances, we will make every effort to coordinate a substitute Clinician to ensure continuity of services.
Agreement of Terms

I have read, understand and agree to all the above Strategies for Learning, Inc. Policies and Procedures.
Name of the parent/guardian:*
E-Signature of parent/guardian:*

Clear
Today's Date:*

MonthDayYear
Should be Empty:

Strategies for Learning: Summer Reading Intensive 2026

Student Information

Summer Reading Intensive Information

Summary of Concerns

Medical History

Parent/Guardian Information

Emergency Information

Informed Consent

Policies and Procedures

Agreement of Terms