Intake Questionaire Name * of person filling out form First Name Last Name Relationship to student * Name of student * First Name Last Name Email * Phone * (###) ### #### Primary Zip Code * Student's Age * Students grade * School District Your Child Attends * Current School Attending * Does the student currently recieve any of these services? * Check all that apply Occupational Therapy Physical Therapy Speech Special Day Class Assistive Technology Hearing of Visiual Aids Pull out services Push in services Counseling 504 IEP Other None In your own words, what is your child's greatest strength? * Briefly describe what you are seeking assistance with How would your student explain their current school experience? (feel free to put it in their own words) * Does the student have any formal diagnosis by a licensed professional? * Please list (put N/A if none) What are your goals and desired outcome for your student? * What would you say are your student's goals? * gifted by sara offers a limited number of scholarships. Would you like more information? * No, a scholarship is not necessary Yes, please send me more information I do not need a scholarship, but would like to contribute to the scholarship fund for a future student I look forward to speaking with you soon!Your’e a gift,Sara
