CHOYCES Tutoring Service parent Consultation Questionnaire Email *example@example.comParent / Guardian Name *First NameLast NamePhone *Please enter a valid phone numberName of child to receive tutoring *First NameLast NameHow old is the child? *What is the child's grade level? *Does your child have an IEP? *YesNoIs your child an English Language Learner (ELL), serviced in English as a Second Language (ESL) or a Multi-Language Learner (MLL) *YesNoWhat subject is your child struggling in *ReadingWritingMathSocial StudiesScienceOtherWhat 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. )? *YesNoDo you have any additional comments? *Proposed days for tutoring? *SundayMondayTuesdayWednesdayThursdayFridaySaturdayProposed time for tutoring? *Morning 8AM - 11 AMAfternoon 11 AM - 4 PMEvening 4 PM - 8 PMI 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 agreeTutor NameTutor Signature *Start signing your signature hereYour browser does not support e-Signature field.Date *Submit