JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Insights into Your Child's Learning Style
Share your observations and insights about your child.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Child's First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Child's Age
*
Your answer
Grade in School 2023-2024
*
Your answer
Names of Schools Attended and which grades at each school.
*
Your answer
Names and Ages of Siblings
Your answer
What is your child passionate about?
*
Your answer
What do you see as your child's greatest strengths and skills?
*
Your answer
What does your child find difficult about school?
*
Your answer
How would you characterize your child's learning style?
*
Your answer
Describe your child's social life.
*
Your answer
Overall, where do you think your child is physically, socially and academically?
*
Your answer
Have you had any evaluations or therapies that would be helpful for me to know about?
Your answer
HOW CAN I HELP?
What sort of educational support are you looking for? Choose all that apply.
*
Developmental Movement Integration
Academic Tutoring
Creative Enrichment
Other:
Required
If you checked Developmental Movement Integration...What are your observations that guide you toward requesting Developmental Movement Integration for your child?
Your answer
If you checked Academic Tutoring...What specific areas of academic tutoring are you interested in? Please be specific.
Your answer
If you checked Creative Enrichment...What creative enrichment options would you most like your child to experience?
social games
therapeutic painting
singing and recitation
wood crafting
puzzles and games
flute/recorder playing
Other:
In what way do you hope your child will benefit from working with me?
*
Your answer
Is there anything else that you would like to share with me?
Your answer
What are your questions?
Your answer
PERMISSIONS
I give my permission for photos or videos of my child to be posted to Space & Grace Learning Website and other forms of advertising such as Social Media and Print Brochures.
*
I agree
I do not agree
Does your child have any allergies or food sensitivities that I should be aware of?
*
Your answer
CONTACT INFORMATION
Parent 1: First and Last Name
*
Your answer
Parent 1: Home Phone and Cell Phone
*
Your answer
Parent 1: Email
*
Your answer
Parent 1: Street Address, City, State, Zip Code
*
Your answer
Parent 2: First and Last Name
Your answer
Parent 2: Home Phone and Cell Phone
Your answer
Parent 2: Email
Your answer
Parent 2: Street Address, City, State, Zip Code
*
Your answer
Rank Your Preferred Method of Contact
Parent 1 Email
Parent 1 Text
Parent 1 Phone
Parent 2 Email
Parent 2 Text
Parent 2 Phone
Landline
1st
2nd
3rd
4th
5th
Parent 1 Email
Parent 1 Text
Parent 1 Phone
Parent 2 Email
Parent 2 Text
Parent 2 Phone
Landline
1st
2nd
3rd
4th
5th
Clear selection
PAYMENT OPTIONS
Scheduling and payment are usually expected before the First Session, and then for the month for additional sessions. After you book your preferred sessions, you will receive an Invoice with the monthly total.
How would you like to pay for your child's sessions?
*
Venmo, includes a 1.95% transaction fee
Zelle
Check mailed
Check hand delivered
Other:
Additional Comments:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
