CHOYCES Tutoring Service parent Consultation Questionnaire

Email *example@example.com

Parent / Guardian Name *First Name

Last Name

Phone *Please enter a valid phone number

Name of child to receive tutoring *First Name

Last Name

How old is the child? *

What is the child's grade level? *

Does your child have an IEP? *YesNo

Is your child an English Language Learner (ELL), serviced in English as a Second Language (ESL) or a Multi-Language Learner (MLL) *YesNo

What subject is your child struggling in *ReadingWritingMathSocial StudiesScienceOther

What are their specific weaknesses in this subject area *

Are there any special legal accomodations or modifications ( on task focusing prompts, breaks, questions, or directions read aloud, use of manipulitives, etc. )? *YesNo

Do you have any additional comments? *

Proposed days for tutoring? *

SundayMondayTuesdayWednesdayThursdayFridaySaturday

Proposed time for tutoring? *

Morning 8AM - 11 AMAfternoon 11 AM - 4 PMEvening 4 PM - 8 PM

I understand that the consultation is free however I will be charged a fee before the first tutoring session, dependent on the amount of sessions chosen *

I understand and agree

Tutor Name

Tutor Signature *

Start signing your signature here

Date *

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