Math Intake Form | Unboggle

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MATH CLIENT INTAKE FORM

Please answer the following questions to the best of your ability.

Student's First name

Student's Last name

Student's Grade Level for the Upcoming School Year

Student's School District (This information will ONLY be used to align school holidays and breaks with the student's district calendar).

Student's Birthday (Month and day only)

Student's Personal Interests

Is the student on grade level? For example, if the student is in 5th grade, can s/he perform math calculations at a 5th grade level? *

Yes

Check all of the student's academic strengths in math. * Required

Enjoys math

Calculations are typically accurate

Has memorized multiplication facts

Can perform mental math

Has good organizational skills

Is able to stay on task

Can follow a series of directions

What goals would you like for your student to achieve through the services provided?

What is your preferred method of payment? *

Apple Pay

Cash

Cash App

Invoicing

PayPal

Zelle

Do you agree to communicate via text as needed? *

Yes

What is your address? This information will ONLY be used for in-person coaching (if applicable), and for occasional mail-outs.

Is there any other information that you would like to share?

Thank you for submitting this information!

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