Math Tutoring

Math Tutoring Intake Form ~Tacia Fields

Please complete this intake form before scheduling your first session. Your answers help me identify skill gaps, set goals, and plan tutoring that fits your student’s needs.Rates: Virtual $50/hr
Name

First NameLast Name
Email
example@example.com
Student Grade Level
School Name
Parent/Guardian Name (required if under 18)
Best Parent/Guardian Email
Best Parent/Guardian Phone Number
Preferred Communication Method
Student Phone/Email (optional)
Course
Teacher Name (if applicable)
Current Grade in the Course
Most Recent Test/Quiz Score(s)
What unit/topic are you currently on?
Biggest struggle right now

Other
Which skills need the most support?

Other
Does the student have an IEP/504 or accommodations?

Other
If yes, what accommodations help most?
Primary goal for tutoring

Other
Important dates coming up (tests, EOC, deadlines)
What would success look like in 4–6 weeks?
Confidence in Math (1–10)

1

2

3

4

5

6

7

8

9

10

1 is Lowest, 10 is Highest
How does the student learn best?
Homework completion right now
Biggest barrier to progress

Other
How often?
Preferred days/times
Device available (Virtual Sessions)

Other
Internet reliability (Virtual Sessions)
Upload or share a screenshot of current grade + missing assignments

Cancelof
Upload a recent test/quiz/study guide (optional but helpful)

Cancelof
Anything else you want me to review before we start?
I understand the rates are:
Cancellation/No-show policy
Academic integrity
Preparedness
Parent consent (required if under 18)
60-Minute Virtual Tutoring Session
60-Minute Virtual Tutoring Session

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USDTutoring sessions are $50 each. Enter $50 for one session, $100 for two sessions, $150 for three sessions, etc. The minimum payment is $50.
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Math Tutoring Intake Form ~Tacia Fields

60-Minute Virtual Tutoring Session*

Payment Methods

60-Minute Virtual Tutoring Session