Student's Name *

First Name

Last Name

Student’s DOB

MM

DD

YYYY

Parent/Guardian 1 Name *

First Name

Last Name

Parent/Guardian 1 Phone *

(###)

###

####

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Phone

(###)

###

####

Program(s) Selection *

Choose the program(s) you would like to enroll your student in.

Preparing for Middle School Success

Preparing for High School Success

Preparing for College Success

Building Executive Functioning Skills

Improving Academic and Study Skills

Developing Leadership Skills

Knowing Yourself, Knowing Others: Social Emotional Learning

Summer Coaching for Summer School Classes

Which scheduling option would you prefer? *

Sessions must be completed before the student returns to school for fall semester.

Once a week coaching for 6 or 8 weeks

Twice a week coaching for 3 or 4 weeks

Please share with us if your student has been diagnosed with any of the following: *

ADHD

Autism or Asperger's

Anxiety

Depression

Learning Differences in reading, writing, or math

Giftedness

Chronic physical conditions that impact learning

None

Has your student had an academic evaluation for a 504 or IEP? *

Yes

No

Unsure

Has your student had an evaluation by a psychologist or psychiatrist? *

Yes

No

Unsure

Does your student have a support plan at school like a 504 or IEP? *

Yes

No