Intake Form | Excellearning

Parent First Name

Parent Last Name

Phone

Address

Student Name

Grade

School Attending

Why do you think your student is struggling?

In what subjects is help needed?

What are your expectations for tutoring?

How do you expect your student to perform in school?

How does your student handle stress?

What does your student's teachers say about their performance in class?

Do you or does your student's teacher(s) have concerns about behavior while at school?

Do you know the type of curriculum or textbook used in the classroom for the subject your student is having difficulty with?

Has your student passed STAR?

Has your student passed EOC for their grade level?

Grades 10-12: Will your student be taking the SAT or ACT?

Grades 11-12: Will your student be taking TSI?

Rate your student's organizational skills

Auditory

Visual

Tactile/Kinesthetic

Not Sure

Please list any known learning differences or challenges:

Does your student have a 504 or IEP?

If so, what types of accommodations or modifications are recommended?

Please describe your student's personality and interests:

Which days/hours best fit your schedule for tutoring?

Are there any additional expectations you have for your student or the tutor at Excel Learning Academy?

Does your student have any medical conditions, allergies, or personality differencess Excel Learning Academy needs to be aware of?

Is there any other information that would be beneficial for your Excel Learning Academy tutor to know about you, your family, or your student?

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