To make sure we provide the most e�ective Sylvan experience possible for your student, please sharethe information below.

Student Name _______________________________ Student Age _______________________________________

Student DOB ________________________________ Student Grade and School_____________________________

Customer Name ______________________________ Relationship to Student _______________________________

Customer Address _______________________________________________________________________________

Customer Email _________________________________________________________________________________

Customer Occupation ____________________________________________________________________________

Customer Phone ______________ Alternate Phone ______________________

Preferred Method of Contact

Customer Name 2 ____________________________ Relationship to Student _______________________________

Customer Address 2______________________________________________________________________________

Customer Email 2 ________________________________________________________________________________

Customer Occupation ____________________________________________________________________________

Customer Phone 2 _____________ Alternate Phone ______________________

Preferred Method of Contact

Sibling(s) Name(s), Birthday(s) & Grade(s) in school _______________________________________________________

_____________________________________________________________________________________________

1. How immediate is your need? (please check one):

___ We urgently need help right away and hope to get help this semester.

___ We are moderately concerned and hope to get help this school year.

___ We are just here to see how our child is doing and get advice for the future.

Street City State Zip Code

Street City State Zip Code

Mobile Work Home Mobile Work Home

Mobile Work Home Mobile Work Home

Phone Alt Phone Email Other

Phone Alt Phone Email Other

Background and Goals

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WELCOME!INFORMATION & OBJECTIVES

Assessment Form

2. We can help! How much time do we have?

___ Less than 3 Months

___ 3 to 6 Months

___ 6 to 9 Months

___ As long as we need

3. Has anyone in your family previously attended Sylvan?

4. If yes, when and where? ________________________________________________________________________

5. What prompted you to reach out to Sylvan and make this appointment? ____________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

6. What is the most important thing you would like to discuss? _____________________________________________

_____________________________________________________________________________________________

7. At what level do you feel your student is functioning?

8. Where would you like to see improvement?

Below grade level At grade level Slightly above grade level Considerably above grade level

9. Please provide any additional information you feel would be important to your student’s success at Sylvan.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

10. What else have you tried and for how long?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Skills Attitudes Habits

Reading Skills

Math Skills

Study Skills

Writing Skills

Test Preparation

Homework

Confidence

Independence

Attitude Towards School

Relationship With Teacher

Attitude Towards Homework

Engagement in Learning

Behavioral / Disciplinary

Self-Discipline

Attention in Class

Study Habits

Homework Consistency

Time Management/Organization

Reading Skills

NoYes

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Assessment Form

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning Afternoon Lunchtime Evening

11. Who referred you to Sylvan? We’d like to thank them! __________________________________________________

_____________________________________________________________________________________________

1. Please indicate any days that do not work for your family as a part of your Sylvan Schedule.

2. Please choose the time of day that is most convenient to schedule conferences and reach you by phone or email.

3. Please indicate what is important to you as you choose a payment option.

____ One time payment discounted depending on hours purchased

____ A�ordable monthly payment plan (Please indicate monthly dollar range) $_______________

4. Is there anything else we should know about your child? ________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Customer Signature ________________________________________________________Date___________________

Practical Considerations

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Assessment Form

Please fill this out if student is in grade 6 or higher.

1. What are the student’s immediate plans after high school graduation?

____ Take time o� before college

____ Gain work experience before college or career

____ Certificate program, associate’s degree or other 2-year program

____ Bachelor’s degree at 4-year college or university

____ Enlist for military service (if so what branch? ____________________ )

____ Other

2. What is your student’s most likely field of interest or major? ____________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

3. If higher education is on your student’s future plans after high school, what schools are the top 3?

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

3. _________________________________________________________________________________________

4. Has student taken ACT, SAT or other admissions tests, and if so what were the results?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

5. If your student is currently in grade 10 or higher, please answer the following:

What is student’s current rank? ___________

What is student’s current GPA? ___________

Has your student earned all credits to date for on-time graduation? ___________

Customer Signature ________________________________________________________Date___________________

Planning for the Future

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Assessment Form