The School House Tutoring Intake Form

The School House Tutoring Intake Form

Please complete this form to help us understand your child's tutoring needs.
Student's Full Name

First NameLast Name
Parent or Guardian's Full Name

First NameLast 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
What subject(s) does your child need support in? (Select all that apply)

Other
What specific challenges does the student face? (Select all that apply)

Other
How would you describe your child's current reading ability?
Does the student have any special learning needs or accommodations?
Please list any special learning needs or accommodations.
Does your child currently receive school-based support? (Select all that apply)

Other
How does your child learn best? (Select all that apply)
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?
Preferred Days for Tutoring Sessions (Select all that apply)
Preferred Times for Tutoring Sessions

Other
Preferred Times for Tutoring Sessions
If a small group becomes available with students of similar grade level and ability, would you be interested in your child participating?
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.
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