Reading Tutoring Intake Form
Please complete this form to help us understand your reading tutoring needs.
Student's Full Name
*
First Name
Last Name
Parent or Guardian's Full Name
*
First Name
Last Name
Parent or Guardian's Email Address
*
example@example.com
Parent or Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student's Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
High School
Other
School Name
How would you describe the student's current reading ability?
*
Below grade level
At grade level
Above grade level
Not sure
What specific reading challenges does the student face? (Select all that apply)
*
Decoding (sounding out words)
Reading comprehension
Vocabulary development
Fluency and speed
Motivation/interest in reading
Other
What are your main goals for reading tutoring?
*
Preferred Days and Times for Tutoring Sessions
Monday Morning
Monday Afternoon
Tuesday Morning
Tuesday Afternoon
Wednesday Morning
Wednesday Afternoon
Thursday Morning
Thursday Afternoon
Friday Morning
Friday Afternoon
Saturday
Sunday
Other
Preferred Tutoring Format
*
In-person
Online/virtual
No preference
Does the student have any special learning needs or accommodations?
*
Yes
No
If yes, please describe any special learning needs or accommodations.
Is there anything else you would like us to know about the student or your tutoring expectations?
Submit Intake Form
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