Parent Intake Form - Headwaters Educational Consulting

Student Information

Student Name *

Student Date of Birth *

Address *

Country

City

State

Zip code

Student Email Address *

Student Cell Phone Number *

Biological Gender *

Male

Female

Age *

Grade *

School *

Applicant lives with: *

Father

Mother

Both Parents

Other

Are you a U.S. citizen? *

Yes

No

Other

In what sports and/or after school activities does the student participate? *

What community groups and/or organizations does the student belong to? *

1st Parent/Guardian Information

Name *

Address (if different from above)

Country

City

State

Zip code

Phone *

Email *

Occupation *

College (if any)

Graduate school (if any)

2nd Parent/Guardian Information

Name

Address (if different from above)

Country

City

State

Zip code

Phone

Email

Occupation

College (if any)

Graduate school (if any)

Sibling Information

Sibling Name

School

Birthdate

Graduation Year

Sibling Name

School

Birthdate

Graduation Year

Sibling Name

School

Birthdate

Graduation Year

Educational History

We also request that you please e-mail us a copy of the student’s transcript and standardized test scores.

Student Class Rank

Student GPA

Has the student taken the PSAT, ACT, or SAT? *

Yes

No

Please list the scores for each section.

Has the student ever repeated a grade? *

Yes

No

What grade was repeated and why?

Has the student ever been tested for a learning disability? *

Yes

No

When and by whom was the student tested?

Was the student classified by the school? *

Yes

No

When was the student classified?

What was the classification?

Is the student still classified?

Does the student have accommodations? *

Yes

No

What accommodations?

Study Skills

On average, how much time does the student devote to homework each weekday night?

Do you have difficulty getting the student to complete homework? *

Yes

No

Please explain difficulties you experience.

Has the student ever been tutored? *

Yes

No

Which subjects and for how long?

Is the student currently being tutored? *

Yes

No

How is the student responding? Do you expect to continue the tutoring?

Please evaluate the student in each of the following areas (1=deficient to 10=exceptional) *

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Reading
Study Skills
Time Management
Organization
Writing/English
Math
Confidence
Motivation