New Student: Intake FormAre you ready to embark on an academic adventure with High Altitude Tutoring? Tell us a bit about your student to get started!Estimated time to complete form: 5 mins Parent/Guardian Info Primary Contact * First Name Last Name Relationship to student * Phone * (###) ### #### Email * What's the best way for us to contact you? Phone Text Email Alternate Contact First Name Last Name Relationship to student Phone (###) ### #### Email Student Info Name First Name Last Name Birthday MM DD YYYY Current School & Grade Address (for home-visits) Skills & Support Areas How would you assess your student's confidence & ability with the following skills? Reading Above Average Average Needs Support Writing Above Average Average Needs Support Math Above Average Average Needs Support French Above Average Average Needs Support N/A Organization Above Average Average Needs Support Why are you hiring a tutor for your student? Do you have any particular goals or concerns? Medical & Disability Check off all that apply: Acquired Brain or Head Injury Attention Deficit Hyperactivity Disorder (AD/HD) Autism Spectrum Disorder Concussion Dyscalculia Dyslexia Dysgraphia Hearing Impairment Learning Disability (please specify) Mental Health Severe Allergy (please specify) Visual Impairment Please include any relevant details Do you have any documentation that may be helpful for us? Recent report card or assessment Individual Education Plan (IEP) Psychoeducational Assessment Thank you!
