New Student Intake Form
Share your student’s strengths and support needs so we can shape services around who they are and where they want to go.
All sessions are held virtually over Zoom.
Parent or guardian (primary contact)
Full name
*
First Name
Last Name
Relationship to student
*
Please Select
Parent
Guardian
Grandparent
Other
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred way to reach you
*
Email
Phone
Text
Best times to reach you
Returning Range Collective contact?
Yes
No
Student (the new client)
Student full name
*
First Name
Middle Name
Last Name
Preferred name
Date of birth
*
-
Month
-
Day
Year
Date
Current grade level
*
Please Select
9th grade
10th grade
11th grade
12th grade senior
Post-graduate
Other
Current school
*
Anticipated graduation date
-
Month
-
Day
Year
Date
Student direct contact info
About the student
What are your student's strengths, interests, and talents? What lights them up?
*
What are your student's hopes for after high school?
Four-year college
Community or technical college
Career or workforce entry
Vocational or job training
Gap year
Still exploring
Other
Which areas would you like support with?
College search applications and decisions
Career exploration and planning
Executive functioning and organization
Self-advocacy and self-determination
Interview and workplace readiness
Independent living and transition skills
Highlands Ability Battery strengths assessment
Other
Any co-occurring profiles it would help me to know about, for example ADHD, dyslexia, anxiety (optional)
Does your student identify as autistic or have an autism diagnosis?
Yes
Prefer not to say
What helps your student communicate and engage best? Think communication style, sensory needs, pacing, or anything that helps them feel comfortable.
Services you are interested in
Services you are interested in
*
Individual Coaching Package (six sessions)
Highlands Ability Battery (HAB) Assessment
College and career readiness coaching
Not sure yet, I would like to discuss
Getting started
How soon would you like to begin?
*
Please Select
As soon as possible
Within 2 weeks
Within 1 month
1–3 months
Just exploring
Other
General availability (days and times that tend to work)
How did you hear about The Range Collective?
Please Select
Friend or family
School or teacher
Website
Social media
Community event
Search engine
Other
Is there anything else you would like me to know about your student or your goals?
Consent and acknowledgment
Submit
Should be Empty: