The School House Tutoring Intake Form
Please complete this form to help us understand your child's tutoring needs.
Student's Full Name
*
First Name
Last Name
Parent or Guardian's Full Name
*
First Name
Last Name
Parent or Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian's Email Address
*
example@example.com
School Name
*
Student's Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
High School
Other
What subject(s) does your child need support in? (Select all that apply)
*
Reading
Writing
Math
Homework Support
Test Prep
Other
What specific challenges does the student face? (Select all that apply)
*
Decoding (sounding out words)
Reading comprehension
Vocabulary development
Math Facts
Word Problems
Writing Sentences
Fluency and speed
Motivation/interest in reading
Other
How would you describe your child's current reading ability?
*
Below grade level
At grade level
Above grade level
Not sure
Does the student have any special learning needs or accommodations?
*
Yes
No
Please list any special learning needs or accommodations.
Does your child currently receive school-based support? (Select all that apply)
*
IEP
504
RTI/MTSS
Speech
Reading Intervention
Other
How does your child learn best? (Select all that apply)
*
Visual
Hands-on
Verbal
Movement Based
What motivates your child?
Any triggers we should be aware of? (ex: timed work, reading aloud, correction, transitions, etc.)
*
What are your main goals for tutoring?
*
How often would you like to receive tutoring services?
1 session/week - $30
2 sessions/week - $50
8 sessions/month - $180
Preferred Days for Tutoring Sessions (Select all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (upon availability)
Sunday (upon availability)
Preferred Times for Tutoring Sessions
3pm - 4pm
4pm - 5pm
5pm - 6pm
Other
Preferred Times for Tutoring Sessions
9am - 10am
11am - 12pm
12pm-1pm
If a small group becomes available with students of similar grade level and ability, would you be interested in your child participating?
*
Yes, I would be interested
No, I prefer individual tutoring only
I'm open to either option depending on placement
Is there anything else you would like us to know about the student or your tutoring expectations?
Please note there is a $20 registration fee for each child receiving tutoring services. All session payments must be made 24 hours prior to receiving any services. The School House accepts Cash, Zelle, Cash App, or Credit/Debit for payments. By signing below you are acknowledging and agreeing to these policies for The School House.
Submit Intake Form
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