Tutoring Intake Form

Tutoring Program Intake Form
Thank you for your interest in tutoring services with the Learning Disabilities Association of Manitoba (LDAM). Please complete the form below so we can better understand your needs. All information will be kept confidential and used only for program planning and communication. Once this form is submitted, you will be placed on our waitlist for services.
Service and Location
What tutoring services are you interested in?
Where would you like to access tutoring services?
Account Holder Information
Account Holder Name

First NameMiddle NameLast Name
Account Holder Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Account Holder Email Address
example@example.com
Account Holder Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method
Student Information
Student Name

First NameMiddle NameLast Name
Student Date of Birth (MM/DD/YYYY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Grade (if applicable)
Student School (if applicable)
Primary Language Spoken at Home
Allergies
Allergies - details
Parental/Guardian Decision-Making Information

(If applicable)
Are this child’s parents/guardians separated, divorced, or subject to a formal parenting arrangement?
Decision-making responsibility for this child in areas relevant to this service
Other Parent/Guardian Name

First NameMiddle NameLast Name
Other Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Parent/Guardian Email Address
example@example.com
Student Learning Profile
Diagnosis (if applicable)
Areas of Concern
Assessments Completed
Is there an adapted learning plan in place at school?
Current Support Services
Has the student participated in Barton Tutoring elsewhere?
If so, which Barton level has been completed?
Billing & Payment
A valid credit card is required on file for all accounts, regardless of payment method (see Tutoring Policies, Section 2 – Payment & Balances). Credit card information will be collected securely during your intake meeting with our Admin Coordinator, which will be scheduled after this form is submitted.
Al tutoring fees are due prior to the start of each term. In some circumstances, tutoring fees can be divided into three (3) equal payments. Is this something you would like to explore?
Additional Information and Signatures
Additional Information (including strengths and interests)
Signature & Confirmation
By signing below, I confirm that:
- The information I have provided is accurate and complete.
- I confirm that I have the legal authority to enroll this child in LDAM programs, and that this enrollment does not violate any custody agreement or court order currently in place.
- I have read and agree to the Tutoring Policies, including Sections 2 (Payment & Balances) and 3 (Cancellations).
- I consent to receiving tutoring services and program communication from LDAM.
- I understand that a valid credit card must be provided and kept on file for my account, regardless of payment method. Credit card information will be collected securely during the intake process.
Account Holder Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Office Use Only
Office Use Only - Intake Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only - Intake Reviewed by

First NameMiddle NameLast Name
Office Use Only - Intake Appointment Completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only - Intake Appointment Completed by

First NameMiddle NameLast Name
Should be Empty:

Tutoring Program Intake Form

Service and Location

Account Holder Information

Student Information

Parental/Guardian Decision-Making Information

Student Learning Profile

Billing & Payment

Additional Information and Signatures

Signature & Confirmation

Office Use Only