Intake form

Name *

Email address *

What grade level are you interested in?

Which subjects do you need assistance with?

Please select at least one option.

Mathematics

Science

English

Social Studies

Languages

Computer Science

Arts

Physical Education

What types of learning challenges do you or your child face?

Please select at least one option.

Dyslexia

ADHD

Autism Spectrum Disorder

Anxiety

What is your preferred mode of learning?

What are your goals for seeking coaching?

Additional questions or comments

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