Wells Academic Solutions

7-Adult Online Client Intake Form

General Info

Parent or Guardian:

Email:

Primary Phone Number:

Secondary Phone Number:

Street Address:

City:

State:

Zip:

Child’s Name:

Preferred Nickname:

Date of Birth:

Grade:

School:

Sex:

How Did You Hear About Us?

Schooling History

Middle School:

High School:

Current Math Class:

Grade:

Current English Class:

Grade:

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?

Learning Behavior

Always

Sometimes

Never

Struggles to complete homework

Overly sensitive to criticism

Difficulty working independently (school)

Difficulty working independently (home)

Has difficulty learning things the first time they are presented

Has difficulty retaining concepts

Has difficulty with memorization

Resistant to reading

Uncomfortable in social settings with peers

Uncomfortable in social settings with adults

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 school and required classes

Has difficulty staying organized

Has difficulty delaying gratification

Parent and child argue about schoolwork / grades

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.):

Questions for the student

For questions 1-3, please use the following scale
1 – not at all and 10 – the most.

1. On a scale of 1-10, how much do you enjoy school?

2. On a scale of 1-10, how much do you enjoy the subject(s)
you are seeking help with?

3. On a scale of 1-10, how motivated are you to do well in school?

4. Is going to college important to you? (We assume that it is important to your parents, but we would like to know your thoughts.)

If yes, then why do you want to go to college? What do you hope to gain?

What are your interests outside of school and academics?

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 7-Adult clients, email us at:
jared@wellsacademics.com

Or fax your form to:
866.324.4625