New Client Intake - TUTORING - Tonya Fitzgerald with JS Therapies

Questions?

Please contact Ms. Fitzgerald directly.

Phone: (207) 831-9954
Email: tonya@jstherapies.com
$50 for initial consultation
$35 for 30-minute sessions
$50 for 60-minute sessions
Pre-pay discounts available

Child's name

Date of birth

Gender

Female Male

Parent/Guardian 1

Parent/Guardian 2

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Alternate phone number

Email address

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City

Zip Code

Physical Address (If Different)

City

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School/Daycare

Grade

May we communicate and collaborate with your child's school staff about services & recommendations?

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Contact information (phone or email)

Does your child have any medical concerns, diagnoses, or allergies we should be aware of?

Parent Questionnaire

AREAS OF CONCERN:

Reading/Phonics

Reading/Comprehension

Writing Skills

Math/Number Sense

Academic Performance

Attention Span/Organization

Other

Other areas of concern not listed above:

Does your child currently receive any other services?

Special Education

Occupational Therapy

Speech Language Therapy

Physical Therapy

Counseling

Behavior Interventions (ABA)

What other evaluations, therapy or special programs has your child had in the past and when?

You can securely share any prior evaluations, IEPs, medical records with us here:

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What are some of your child's interests?

What motivates your child?

Does your child enjoy school?

What else would you like us to know about your child?

Do you have any preferred days/times for regular weekly appointments?

Please specify if there are any days/times you are NOT available.

How did you hear about us?

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JSTherapies staff

Pediatrician

School/Daycare

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Thank you for choosing JS Therapies, we look forward to helping your child reach their potential!

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