Tutoring Questionnaire

In order to better serve your tutoring needs, we ask that you complete the following information which will be used as a tool in assessing your needs.

Name*
First Last
Primary Email Address*
Primary Phone Number*
Relationship to client*
I am interested in:*
- Tutoring
- Advising
- Coaching
Preferred Contact Method
- Please Call Me
- Please Respond by Email
I would like to schedule an appointment for:*
- In Person
- Online
Medical History of individual in need of an evaluation:*
Family History*
Does the individual have a first degree relative(s) with a history of learning/reading disorders?
Presenting issues that require evaluation:*
History of previous interventions, if any:*
- * Full payment or a purchase order and signed contract is required prior to scheduling tutoring sessions.