Academic Coaching Application - Aplus Skills Tutoring

Student Information

Student's First Name

Student's Last Name

Student's Phone Number

Student's E-mail Address

Student's Gender

Student's Date of Birth

Parent Information

Parent's First Name

Parent's Last Name

Parent's Phone Number

Parent's E-mail

Parent Address

Emergency Contact First & Last Name

Emergency Contact Phone Number

Emergency Contact E-mail

Student's Academic Information

Student's Grade

Student's School

Student's School Zip Code

Student's GPA Range

Student's Anticipated Graduation Date

Please describe any medical, visual, hearing, or learning issues that we should be aware.

How did you hear about A+ Skills?

To whom may we thank your referral? (If you were not referred to A+ Skills, please place an "X" in this box.)

Authorization to Contact Teachers and Counselors

Guidance Counselor First & Last Name

Guidance Counselor E-mail Address

By checking this box, I authorize A+ Skills Tutoring to contact my guidance counselor and teachers at any time regarding my academics. I also authorize A+ Skills Tutoring to view my grades with me. Should I wish to remove this consent, I understand that I must e-mail management@aplusskills.com, as verbal communication will not be accepted by our office.

Student's School Schedule Information & Grades

Please enter in ALL requested information. Any missing information will be requested at your first session.

Period 1 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Period 2 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Period 3 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Period 4 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Period 5 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Period 6 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Period 7 Class Name, Teacher Name, Teacher E-mail, AND Current Grade Percentage in the Class

Special Accommodations Information

Do you have an IEP? Yes No

Do you have a 504 Plan? Yes No

If you selected YES to either an IEP or 504 Plan, please upload the most recent IEP or 504 Plan document you have on record from your school. If you do not have access to an online copy, please bring in a paper copy for our office to scan in at your first session.

Academic Obstacles and Goals

Where do you need assistance improving? Select ALL that apply.

Schedule organization Yes No

Binder organization Yes No

Canvas/FOCUS gradebook monitoring and organization Yes No

Time Management Yes No

Procrastination Yes No

Study Skills Yes No

Note-taking Yes No

Motivation Yes No

Goal Setting Yes No

Communicating with Teachers Yes No

Test-taking strategies Yes No

Reducing test anxiety Yes No

If you would like to be tutored in SPECIFIC subject areas that you know you are having trouble with, please list ALL subjects here. If this does not apply to you, place an X in this box.

When you have an exam or major project, how far in advance do you start studying or preparing for the exam? Select ONE.

Briefly describe how you study for tests and quizzes.

If you experience test anxiety, rate your test anxiety from 0 (no test anxiety) to 10 (major test anxiety).

Please answer each of the following by selecting one: ALWAYS, USUALLY, SOMETIMES, RARELY, or NEVER.

When I go to class, my materials are well organized.

I am able to stay focused during class.

After a lecture, I can summarize what was presented.

My notes help me adequately prepare for class.

I work hard in school.

I believe I am capable of being a successful student.

I feel that I manage my time well.

I attend all of my classes every week.

I complete my homework and other assignments on time.

I put off “fun” when I need to study or do school work.

Extracurricular Activities

Do you have a job? Yes No

If you answered yes, please write your typical work schedule and approximate number of hours spent working per week.

Please list any additional extracurricular activities you participate in (sports, community service, personal interests, etc.) and approximately how much time you spend with each activity. If none, please place an X in this box.

Student (and Parent) Agreement for Successful Academic Coaching

Academic success coaching is about helping you build resilience and succeed in achieving your set academic goals. Coaching is not counseling, therapy or academic advising. Coaching is in addition to the many other student services available to you. Your coach may recommend another service for a particular form of support that goes beyond the boundaries of coaching. It is up to you to follow up, if you choose to do so. You are expected to be fully present for coaching sessions, bringing issues or areas for discussion into the conversation. You need to be fully committed to your own learning by responding to messages and attending scheduled coaching sessions.

You are expected to maintain your goals and be honest. What you put in will be what you get out, so please always try your best! Your coach is here to assist you and keep you on track, but you as the student are responsible for following through with suggestions and recommendations by your academic coach. I understand that academic coaches are not counselors, and are therefore not bound by HIPPA. 2. I understand that all comments and ideas offered by my coach are solely for the purpose of aiding me in exploring options. 3. I understand there may be times my coach offers a referral to another service and/or community support, and that I can choose to decline the referral.

By checking this box, I acknowledge that I have read and understand what is expected of me as a student and as a parent for successful academic coaching and agree to all terms and conditions.

By checking this box, I understand that if I wish to opt out of academic coaching services at any time (whether it is to continue with general subjects tutoring only or you have completed services with A+ Skills Tutoring), I am required to e-mail management@aplusskills.net with my cancellation of services request. A+ Skills will NOT accept verbal or text communications regarding a service cancellation or adjustment.

Scheduling & Cancellation Policy

I have read, understand, and agree to the policies and terms of A+ Skills' Scheduling & Cancellation Policy found on their website at: https://aplusskillstutoring.com/scheduling-cancellation-policy.htm

OFFICE HOURS - I understand that A+ Skills Tutoring is closed on Friday and Sunday in Naples, FL and only on Friday in Fort Worth, TX. All calls and e-mails received on the days we are closed will be returned the next business day. Please leave us a voicemail or e-mail management@aplusskills.net. To cancel or reschedule, please e-mail management@aplusskills.net.

Please click on submit ONCE to submit your application! You will be redirected to the final step of your application process: submitting payment.