Form 1: Parent/Guardian Intake Form

A

Student Full Name *

Date of Birth

Current Grade Level

School Name

Subject Focus

Reading & Writing Math Science Study Skills/Executive Function Test Prep Other

Today's Date

B

Parent/Guardian Full Name *

Relationship to Student

Phone Number *

Email Address *

Mailing Address

Best Time to Contact

Preferred Communication

Phone Email Text Other

C

Main reason for seeking tutoring *

D

Check all that apply:

E

Check all that apply:

F

G

Goal 1

Goal 2

Goal 3

What would meaningful progress look like in 4-6 weeks?

What does success look like at the end of the first tutoring cycle?

H

"I confirm the information above is accurate and consent to Luma Tutoring Studio using it to design my child's personalized tutoring plan."

Parent/Guardian Signature

Date