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KoolMinds New Student Intake Form
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* Indicates required question
Student's Name
*
Your answer
Home Phone number
*
Your answer
Email Address
*
Your answer
Address
Your answer
City, State and Zip Code
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Gender
Male
Female
Clear selection
How were you referred to us?
Your answer
Student's grade
Your answer
Retained? Yes/No , if Yes what grade were they retained?
Your answer
Name of School and is it public or charter/private
Your answer
Does your student currently have an IEP or 504? Yes/No , if Yes is the SLD box checked? Y/N
Your answer
Please complete Parent Information if student is under 21 years of age.
Parent 1: Please include name, cell phone and email address
Your answer
Parent 2: Please include name, cell phone and email address
Your answer
Marital Status of parents
Your answer
Emergency Contact: Please include name, address, cell phone and email address
Your answer
Summary of Problem
Your answer
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