Private Sessions Intake Form

Instructor: Julie Miller

Please fill out this intake form as soon as possible so that Julie has time to review it prior to your first session. Thank you!

Name*
First Last
Email Address*
Phone Number*
Secondary Phone Number
I registered for:*
The participants in these sessions will be:*
Name of Primary Participant (if other than above)
First Last
Preferred Pronouns
Other Session Participants (if applicable):
Please provide the full name of each participant, their preferred pronouns, and their relationship to the primary participant. Remember, if the primary client is a student, a least one parent or adult support figure MUST attend the sessions as well.
General Intake Information
Primary Concerns
Please identify any of the following that apply to the primary client(s):
ADD/ADHD, Dyslexia, Learning Differences, Gifted and Talented, Processing Disorders, Premature Birth, Adopted, Mental Health Diagnosis
Referral Source*
Please let us know how you heard of us.
Additional Questions for Students and Families
Please fill out this section if the primary participant is a student.
Student Age(s)
Current School(s)
Current Grade Level(s)
Payment Policy*
- Yes, I understand the payment policy
I understand that the course includes 10 1-hour sessions, paid in advance of completion. If I desire or need additional 1-hour sessions beyond the 10-session package, I'll be charged for the individual session and must pay in advance of the session.
Cancellation Policy*
- Yes, I understand the cancellation policy
I understand that there is a 72-hour cancellation policy for private sessions. I understand that if I cancel within the 72-hour window, I will need to purchase an additional session to make it up.
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Instructor: Julie Miller

General Intake Information

Additional Questions for Students and Families