Client Request Form

*Due to a large volume of client requests, clients who are interested in meeting regularly will be given priority in
meeting times. Email the completed form to alexis.wehr@gmail.com
Client Contact Information
Name:
Age:
Occupation:
Phone number:
Email address:
Preferred method of contact (underline one): Text Phone Email
Preferred time of contact:
I am the (underline one): Student Parent Other:

Students Education Background
Student Name/Age (if different from above):
Current School:
Most Recent GPA:
Average Math Letter Grade:
Math course to be tutored:
Course Meeting Time:
Most recent test percentage or type Not Applicable if none have been taken:

Please underline one option in the following statements:
Strongly Disagree = SD Disagree = D Neutral = N Agree = A Strongly Agree = SA
Thinking only about previous math experiences,
1. I always complete my homework assignments: SD D N A SA
2. I always study for a test: SD D N A SA
3. I enjoy math: SD D N A SA
4. I am confident in my ability to complete a problem: SD D N A SA
5. I lack basic math skills: SD D N A SA
6. My teacher is a big problem in my understanding: SD D N A SA
7. Math is relevant to my life: SD D N A SA
8. I care about my grade: SD D N A SA
9. I never procrastinate: SD D N A SA
10. I am good at math: SD D N A SA
11. I am comfortable asking questions: SD D N A SA
12. I try my best: SD D N A SA
13. I strive for understanding: SD D N A SA
14. Each chapter connects with the previous chapter: SD D N A SA

Please provide me with any additional information you feel I need in order to assist you
(Examples include: disabilities, previous 504 plans or IEPs, stories from previous classes,
tragic events that are hindering your ability, etc) or type Not Applicable:



Schedule an Appointment
At least one requested appointment must be no sooner than 48 hours in advance.
Locations must be public; my most preferred locations are libraries, cafes, and dorm/apartment
common rooms. If you would like to meet in a library, I recommend trying to reserve a study
room as to not disturb the other patrons.
Please provide me with three options for the first tutoring session (month/day, time, location):
Example: 8/29, 10 AM, Science and Engineering Library
1.
2.
3.
I would like to meet (underline one): weekly bi-weekly as needed
I have a regular meeting time I would like to request (day of week, time, location) or type Not
Applicable [Example: Tues/Thurs, 3:00 PM, Coffee Exchange]: