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Gerneral Information
Student Name:
Last Name
Nickname:
Address:
City:
Zip
Home Phone:
Parent information
Parent 1 Name :
Parent 1 Cell Phone :
Parent 1 Email:
Parent 2 Name :
Parent 2 Cell Phone :
Parent 2 Email:
Child Grade:
Child Birth Date:
Child Gender:
Male
Female
Allergies
Check all areas you are concerned with
Reading Skills (my child needs to improve in reading comprehension, reading fluency, and vocabulary)
Math Skills (my child needs to improve in basic math skills, word problems, and math test-taking skills)
Algebra I, Algebra II, Geometry (my child needs to improve in higher level math skills)
Writing Skills (my child needs to improve in writing composition, English Grammar, and Language Arts)
Enrichment/Honors (my child is doing great in school but needs enrichment during the school year)
Special Services (check all that apply)
Resource Program (RSP)
Speech Therapy
School Counseling
Reading Intervention Class
Math Intervention Class
After-School Tutoring
Occupational Therapy
Psychological Counseling (private)
504 Educational Plan
None of the above
Diagnosed Conditions (check all that apply)
ADD
ADHD
Learning Disability (auditory/visual)
Speech or Language Deficit
Dyslexia
Behaviorally or Emotionally Challenged
Autism
Neurological Disorder
My child is taking medication to help with school.
If yes, please let us know the Doctor's name:
Name of medication:
Basic Skills
Reading Comprehension
Very Weak
Weak
Average
Strong
Very Strong
Reading Words
Very Weak
Weak
Average
Strong
Very Strong
Spelling
Very Weak
Weak
Average
Strong
Very Strong
Basic Math (+, -, x, ÷)
Very Weak
Weak
Average
Strong
Very Strong
Math Word Problems
Very Weak
Weak
Average
Strong
Very Strong
Writing
Very Weak
Weak
Average
Strong
Very Strong
Performance Skills
Concentration and Focus
Very Weak
Weak
Average
Strong
Very Strong
Test-Taking
Very Weak
Weak
Average
Strong
Very Strong
Motivation
Very Weak
Weak
Average
Strong
Very Strong
Confidence
Very Weak
Weak
Average
Strong
Very Strong
Study Skills
Very Weak
Weak
Average
Strong
Very Strong
Homework Completion
Does your child have trouble getting homework completed on time?
YES
NO
Does your child get frustrated with homework?
YES
NO
Are you frustrated with homework time....?
YES
NO
Check all that apply
Your child's teacher has recommended outside help at a parent-teacher conference, in a progress report, or at report card time.
Your child's grades have started to fall independent of how hard he or she seems to be working, where before they were alright.
No matter how long your child spends on homework, it's neither complete nor accurate.
Your child seems to be experiencing frustration, and shows an increasing lack of confidence and motivation.
Your child has lost interest in learning.
Your child experiences extreme anxiety before tests and exams.
Your child is reluctant to go to school, fearing failure and criticism from others.
Your child's teacher reports that he or she is acting out, becoming a behavior problem in class.
You have heard your child say, "'I'm too stupid. I'll never understand this stuff."
Your child says, " give up." Or, worse, you hear yourself saying it.
Your child is not turning in homework assignments.
Send
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