SE Collective: Arts and Services LLC – Creative Arts & Professional Services

Tutoring Services Student Information Form

* Indicates required question

Name *

Age *

Grade *

Does the student currently perform on grade-level based on state test scores, classroom assessments, etc.? *

If not, please advise which areas are showing the most struggle and the feedback you have been given from school.

Primary learning concern to focus on: *

Secondary learning concern to focus on: *

Does the student currently have an IEP, 504, or diagnosis of a neurobiological or learning disability? *

If yes, which one? If no, do you suspect there may be a disability that is undiagnosed and are hoping to gain more information on this from a baseline skills assessment and tutoring?

Is the student independent with the use of tech? *

YesNo

Would the student likely be more successful with in-person or virtual sessions? *

In-personVirtual

Does the student struggle with executive functioning or attention issues? Please explain. *

Does the student have a diagnosis of ADD, ADHD, ODD, or any other behavioral issues? Please explain which one and how the diagnosis manifests. *

Does the student enjoy the subject they are struggling in despite the struggle? *

Is the student receiving any additional services outside of school? Please explain. *

Please provide any additional information you feel may be helpful for me. *

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Tutoring Services Student Information Form

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