RISE Literacy Center Student Intake Form
Contact Information
1. Name of person completing this form *
Your answer
2. Mailing Address (including city and zipcode) *
Your answer
3. Home Phone:
Your answer
4. Cell Phone: *
Your answer
5. Email Address: *
Your answer
Once admitted I would like to receive the following emails:
6. Student Information:
7. Student Name *
Your answer
8. If minor, name of parent(s)/guardian(s) *
Your answer
9. Date of Birth *
MM
/
DD
/
YYYY
10. Age *
Your answer
11. Grade: *
Your answer
12. Current School: *
Your answer
13. Has student ever repeated a grade? *
Required
14. If yes, which grade(s)
Your answer
15. Has student ever been tested for learning difficulties? If yes, when and where? *
Your answer
16. Is the student currently on an IEP? *
17. Section 504 Plan? *
18. If yes, do you have copies of educational reports/IEP? *
19. If student is reading below grade level, at which grade level are they reading? *
Your answer
Medical History
20. Has student experienced hearing, vision, or speech difficulties or been diagnosed with a physical, cognitive, or mental health condition such as ADHD, ear infections/tubes, asthma, autism spectrum, etc.? If yes, please describe. *
Your answer
21. If yes, diagnosed when and by whom?
Your answer
22. Does student take medication on a regular basis? *
23. If so, what medication?
Your answer
24. Was there any unusual/significant issues during pregnancy/delivery, early childhood development, etc.? History of trauma? If yes, please describe. *
Your answer
25. Is there a family history of reading/learning difficulties? *
26. Any other information you feel would be helpful?
Your answer
27. Academic Background
28. Have you, or current/previous teachers, had concerns about performance in any of the following areas? (Check all that apply) *
Required
29. When were the previous concerns identified and by whom? *
Your answer
30. Please identify student's strengths, interests, favorite classes, etc. *
Your answer
31. RISE
32. Please explain your primary reason(s) for contacting the RISE Literacy Center: *
Your answer
33. What is the goal or desired outcome? *
Your answer
34. How did you hear of the RISE Institute for Literacy? (please check all that apply) *
Required
35. Tutoring Availability
The RISE Literacy Center tutoring sessions are between 3:00 p.m. - 6:00 p.m. Monday through Thursday. Tutoring appointments last about 45 minutes and are scheduled on the hour.
36. Which days would the student be available for tutoring? Select all that apply: *
Required
37. What is your preferred time for tutoring? Select all that apply: *
Required
38. Additional scheduling needs/information:
Your answer
Thank you!
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