Client Intake Form Homework Helpers Marin
Please complete the following survey so that we can best understand you and your needs
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Email *
Student's Name *
Parent 1 Name *
Relationship to Student *
Parent 1 Cell Phone Number *
Parent 2 Name
Relationship to student
Parent 2 Cell Phone Number
Parent 2 Email
Student Grade Level (K-12) *
School Student Currently Attends *
Student Street Address *
Student City and Zip Code *
I agree to pay Homework Helpers Marin for services provided within one week of receiving invoice/payment request - please enter you electronic signature below *
Please write your name below if you agree to this statement: I understand that the standard rate for a Homework Helpers of Marin Academic Coach is $60/hr.  Rates do vary depending on frequency and the needs and level of academic support needed by each student. *
Tell us why you have contacted Homework Helpers Marin:
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