Parent Name
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First Name
Last Name
Parent Email Address
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Parent Home Phone
(###)
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Parent Cell Phone
(###)
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Student Name
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First Name
Last Name
Age
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School Name
Current School Type
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Public School
Private School
Charter School
Home School
Boarding School
Share the history of your student's school type since kindergarten.
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Current Grade Level
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Math Grade Level
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Which best describes your student's learning style?
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If you answered "other" to the previous question, please explain below.
Describe your student's attitude toward and confidence level in math.
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Which best describes your student's math skill level
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Excellent
Above Average
Average
Below Average
Poor
Which best describes your student's math aptitude?
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My student performs well in math with minimal effort.
My student performs well in math as a result of hard work.
My student performs as an average math student even with hard work.
My student performs poorly even when working hard.
My student does not work hard in math.
Other
If you answered "other" to the previous question, please explain below.
Please list your student's math percentile history from their standardized test scores.
(Include the test names and dates taken.)
If you answered "other" to the previous question, please explain below.
If you answered "other" to the previous question, please explain below.
Do you suspect that a learning challenge is affecting your student's math performance?
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Yes
No
If you answered "yes" to the previous question, please describe below.
Has your student been diagnosed with learning challenges that could be affecting math performance?
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Yes
No
Currently being tested
If you answered "yes" to the previous question, please describe below.
Please list your student's math curriculum history from kindergarten to the present.
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(Wherever possible, include title, publisher, % of text completed and whether manipulatives were used)
Which curriculum has your student enjoyed most and why? In which curriculum has your student thrived most and why?
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Which best describes your student's learning preference as it relates to math curriculum?
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My student thrives most with curriculum that promotes autonomy and self-teaching.
My student thrives most when receiving live or DVD math instruction.
My student thrives most with a combination of the prior approaches.
Other
If you answered "other" to the previous question, please explain below.
Which curriculum do you prefer most and why?
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Who is your student's primary math instructor?
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How many days per week does your student receive math instruction?
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4-5
3-4
2-3
1-2
0-1
What role have you played in your student's math instruction over the past several years?
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What role do you hope to play in your student's math instruction in the future?
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Which best describes your most comfortable role in your student's math instruction?
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I am most comfortable serving as my student's primary math instructor.
I am most comfortable serving as my student's math tutor.
I am most comfortable holding my student accountable to completion of HW and tests as they work independently.
I prefer not to be involved at all with my student's math instruction.
Describe your attitude toward and confidence level in math.
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Are you planning for your student to achieve a certain math level by a specific grade (i.e. for PSAT/SAT or other purposes)? If so, please explain below.
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If you have any indication of your student's career interests or natural aptitudes, please list below (i.e. STEM, liberal arts, etc)?
Please share any additional information that you deem relevant.
