Seeley Test Pros - Student Information
Academic Coaching/ Study Skills Tutoring 2022
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Student Name: *
Parent Name: *
Student Phone Number: *
Parent Phone Number: *
Student Email Address: *
Parent Email Address: *
City of Residence *
Student's Grade Level *
Student's School: *
Student's Cumulative GPA: *
Student's Current Math Course:
Student's Current Science Course:
Student's Current English Course:
Student's Current Social Studies Course:
Does this student take any advanced, honors, AP, or IB courses:
What subjects tend to be areas of strength for this student? *
What subjects tend to be areas of concern for this student? *
What struggles or challenges in life contribute to stress at school? Be as specific as possible (divorce, siblings, depression, eating disorders, bullying, etc.) *
What specific issues would you like addressed by tutoring? Check all that apply. *
Does this student have an IEP, 504 or learning plan? *
If you answered yes to the previous question, what kind of accommodations do they receive?
What is the student's current motivation level for tutoring: *
What style of tutoring would this student benefit most from? *
Do you have a preference for a specific Seeley Test Pros tutor? If so, please list the name below.
When does the student often have availability for tutoring?
8:00am-3:00pm (During a free period at school
Unavailable this day
What location(s) could this student meet their tutor? *
How many hours of tutoring does the student anticipate needing weekly? *
For how long does the student anticipate scheduling tutoring? *
Has the student been tutored by another individual or company? If so, with whom or what company? *
Has this student been referred to Seeley Test Pros by a specific individual? If so, please list their name(s): *
How many hours of tutoring are you requesting at this time? Payment can be made by cash, check, Venmo or Paypal (5% fee). *
Seeley Test Pros will attempt to accommodate scheduling changes, but only with a minimum of 24-hours notice prior to the scheduled tutoring appointment. Notice must be provided by phone, directly to the instructor. If email and/or text communications of the cancellation are provided, such are only effective upon the receipt and responsive confirmation by the instructor. Cancellations with less than 24-hours advance notice will result in a charge of the full amount of the scheduled time. In the case of inclement weather (e.g., snowstorms) and emergencies, Seeley Test Pros will make a determination on fee waivers for late cancellations due to emergencies. *
This form completed by: *
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