Individual Support Request

We collect this information to understand your child’s support needs, goals, and scheduling preferences for individualized services.

Parent / guardian first name

Parent / guardian last name

Primary Email

Secondary Email

Phone

Child Name

Grade

School

Does your child have an IEP, 504, or identified learning needs?

Preferred days/times:

Weekday afternoons

Evenings

Weekends

Flexible

Preferred session frequency:

1x per week

2x per week

3+ times per week

Other

Anything you would like us to know before we follow up?

I understand that individual support sessions are scheduled in advance and may be counted as completed if missed or cancelled without sufficient notice. This is a request and does not confirm services.