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Student Profile
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* Indicates required question
Email
*
Your email
Student's Name
*
First and last name
Your answer
Student Age
*
Your answer
Student Age and Current Grade Level
*
Your answer
School
*
Homeschool
Private/Parochial School
Public School
Other:
Required
I am interested in receiving
*
Private Tutoring
Small Group Workshops
Other:
Required
I would like to receive services
*
iNSPiRE the CHiLD in Somers, NY
online
Other:
Required
Days/times preferred
*
Your answer
Parent's or Guardians Name
*
First and last name
Your answer
Consultation Date:
*
MM
/
DD
/
YYYY
Address and Phone number ( List all applicable)
*
Your answer
What are some things the student enjoys doing?
Your answer
What are some of the student's strengths?
Your answer
What are some of the challenges the student is facing?
Your answer
What are your greatest concerns for the student?
Your answer
Tell me about any special services the student has received.
Your answer
Describe how the student learns best.
Your answer
What goals would you like to see met through our tutoring center? Tell me more about what you are hoping to see accomplished.
Your answer
Is there anything else I should know about the student that would help us be successful?
Your answer
How did you hear about iNSPiRE the CHiLD?
*
Your answer
Send me a copy of my responses.
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