Parent Questionnaire

I look forward to working together to help your child reach their educational goals! Please fill out the following questionnaire to help me get to know your child and create an individualized action plan.


Email *
My child attends ( name of school ) *
My phone number is  *
My name is 
My email is 
How did you hear about my business?
If other, please provide information on how you learned about my business
My child's greatest strength is
My greatest learning concern is
My child approaches learning with
I am interested in
My child is in ______________ grade.
My child needs help in
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Does your child have any special needs?
My child is motivated by
Three words that describe my child are
The best day(s) to schedule an assessment is (Assessments are $75)
MM
/
DD
/
YYYY
The best day(s) for tutoring for my child is (are)
The best time(s) for tutoring for my child is (are)
(Summer Hours are M-TH 9am-12pm and 4pm-7pm)
(School Year Hours are M-TH 4pm-8pm and Sat 9am-1pm) Central Time
This budget fits me best...
(1 day/wk is $260, 2days/wk $480/mo, and 3 days/wk $660/mo)


 *
A copy of your responses will be emailed to .
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