Wells Academic Solutions

Pre-K - 6th Online Client Intake Form

General Info

Parent or Guardian:

Email:

Home/Work Phone:

Cell Phone:

Street Address:

City:

State:

Zip:

Who referred you to us:

Student Name:

Preferred Nickname:

Date of Birth:

Grade:

School:

Teacher:

Sex:

How Did You Hear About Us?

Schooling History

Preschool:

Dates of Attendance:

Elementary School:

Dates of Attendance:

Has your child ever repeated a grade?

If so, please explain:

Has your child ever skipped a grade?

If so, please explain:

Has your child ever been evaluated for a learning/attention disorder?

If so, by whom and when?

Has your child ever received speech, vision, or occupational therapy?

If yes, where did he/she receive services?

Does your child have a history of ear infections?

If yes, please describe the frequency and ages of occurrence:

Learning Behavior

Always

Sometimes

Never

Struggles to complete homework

Overly sensitive to criticism

Resistant to parental assistance on schoolwork

Difficulty working independently (school)

Difficulty working independently (home)

Tends to not learn things well the first time they are presented

Has difficulty retaining concepts

Has difficulty with memorization

Resists reading for extended periods of time

Takes jokes literally/does not appreciate sarcasm

Has difficulty relaying a story in chronological order

Has difficulty with concepts of time

Has difficulty with concepts of coins/money

Is easily distractible

Difficulty going to sleep or staying asleep

Often appears restless

Fidgets or moves around in seat while working

Has difficulty remaining seated

Questions the purpose of schooling and/or specific subject matter

Enjoyed books at a young age

Enjoys reading

Comfortable in social settings with peers

Comfortable in social settings with adults

Current Concerns

Please describe your current concerns (subject matter difficulty, lack of interest in
reading, behavior, motivation, grades, etc.):

Goals

Please describe your expectations for results at our center (improvement in grades, attitude, behavior, motivation; understanding of material in a specific subject; overall ease of completing school work; etc.):

Download The Form

You also have the option to download and complete our PDF version of the client intake form. This can be done by clicking on the client intake image below, and saving the file to your hard drive. it can then be filled in using Adobe Acrobat 8 and emailed, or by printing it out and faxing it back to us.

For K-6th clients, email us at:
vloh@wellsacademics.com

Or fax your form to:
866.324.4625