Academic Skill Building

Client Information

First name

Last name

Date of birth

Gender

School

Grade

First name

Last name

Phone number

Email address

Relationship to child

Address

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

In case of an emergency, do we have permissions to contact this person?

Yes No

Has the child previously received services with Creative Therapy?

Yes No

Has the child previously received tutoring services? If so, was it successful?

Yes No

Does your child have allergies?

Yes No

Please list allergies

What areas and subjects are you looking to develop?

Is your child attending school?

What are your child or youths interests?

Does your child have an iep or student success plan?

Yes No

How many sessions are you looking for per week?

Does the child have any pre-existing medical conditions?

Is there anything else regarding the child's medical history that we should be aware of?

What are your preferred session times and days?

Are there strategies that are helpful to utilize when supporting your child?

How does your child learn best?

Is there anything else you'd like to tell us about?