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A+ CLIENT OPENING EVALUATION
SECTION A – DEMOGRAPHIC INFO
Student Firstname:
Student Lastname:
DOB:
Subject(s):
School Grade (ie 10th ):
Mom:
Dad:
Street Address:
City:
Zip:
Home Phone:
Home Fax:
Mom Work Phone:
Mom Cell Phone:
Dad Work Phone:
Dad Cell Phone:
Student Email:
Mom Email:
Dad Email:
SECTION B - BEHAVIORAL INFO
Receptive to tutoring?
Yes
No Uncertain
Tutor Gender Preference?
M
F Tutor Name
Interests/Activities:
Student Goal(s):
Incentive(s):
Parent Goal(s):
SECTION C – COMMUNICATION INFO
Teacher Conference set up?
Yes
No When ?
By what means is the parents and the school
communicating?
WEB
EMAIL
PHONE
PROGRESS REPOSRT
How Often? :
SECTION D - ACADEMIC PERFORMANCE INFO
Beginning Grade or % :
Last Class in Subject :
Letter Grade:
When?:
Related Strengths:
Related Challenges:
(ie ADD, ADHD, Dyslexia)
504/IEP Disability Area(s) :
Medical Conditions :
Medications:
SECTION E - CHOOSE SERVICE
CertifiedTeacher
NonCertified Teacher
Single Session
$69
$59
6 Packs
$396
$3
36
10 Packs
$630
$530
A+ Tutoring and Test Prep, LLC.
Box 55263 • Phoenix • AZ • 85078
(602) 703-3901
