New Client Intake Form

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Email *

Name of Parent(s) or Guardian(s) *

Name of student(s) and age(s) *

Student's birthdate *

YYYY

Student's grade *

Parent cell phone *

Nanny, babysitter, or other caregiver - name and phone number (if applicable)

Does your child have a diagnosis of dyslexia, dyscalculia, or ADHD? *

Yes, I will provide a copy

Explain any support services that your child receives at school. If your child has an IEP, please email me a copy.

What are your hopes and concerns for your child? Why did you decide to pursue private tutoring? *

Did anyone refer your child for tutoring? If yes, please share who so I can thank them! *

Which type of lessons are you interested in? *

Online

In person (Preston Royal Library)

Other

I understand that I must schedule at least 2 sessions per week, as any less would not allow for consistent progress.
*

I understand and agree.

I cannot commit to 2 sessions per week at this time.

What is your child's availability? Please list as many options as possible - day and time *

School year tutoring sessions will begin the week of September 1st, with the first session of the season on Tuesday, September 2nd.
*

I understant that tutoring will begin the week of September 1st, 2025.

Tutoring location preference: *

Preston Royal Library

My home (within a 5 mile radius of 75229)

My home (outside a 5 mile radius of 75229)

Virtual

Until you get an email confirming your child's spots for this year, you are not on my schedule! Please be patient as I work on making a schedule that accommodates all of my students, and reach out with any questions! Looking forward to a great year!
*

I understand and will expect a confirmation email before the end of August.

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