Skip to content
Tutoring Intake Form
*
1.
Full Name:
(Required.)
*
2.
Student’s Name:
(Required.)
*
3.
Email
(Required.)
*
4.
When helping my student with their school work, I often feel (select all that apply):
(Required.)
Concerned
Frustrated
Worried
Overhelmed
Anxious
Impatient
Underprepared
Determined
Supportive
Patient
Empathetic
Invested
Other (please specify)
*
5.
When helping my student with their school work, I would like to feel (select all that apply):
(Required.)
Competent
Effective
Prepared
Supportive
Successful
Empowered
Connected
Resourceful
Encouraged
Fulfilled
Other (please specify)
*
6.
The reason I’m looking for a tutor is:
(Required.)
*
7.
An average tutoring session includes:
(Required.)
*
8.
My student has the following learning differences/challenges (select all that apply):
(Required.)
Dyslexia
ADHD/ADD
Dyscalculia
Dysgraphia
Auditory Processing Disorder
Visual Processing Disorder
Autism Spectrum Disorder
Executive Functioning Disorder
Specific Language Impairment
None of the above
*
9.
My student needs help in:
(Required.)
English/Language Arts
Reading
Math
Science
Civics/History
SAT/ACT Prep
*
10.
Student Availability
(Required.)
Sunday Morning
Sunday Evening
Monday Evening
Tuesday Evening
Wednesday Evening
Thursday Evening
Friday Evening
Saturday Morning
Saturday Evening