Consultation Form
Welcome!
I am excited to begin working together. Kindly complete the following form to help me prepare for our first meeting.
If you're receiving this form to add a second child, scroll to the bottom and click the green button that says, "Add an additional student".
I can't wait to meet you!
Miss Dori
PARENT / GUARDIAN INFORMATION:
First Name
Last Name
Email
Second Email or Spouse's Email (if applicable))
Cell Phone
Address
City
Province / State
Country
Select country...
United States
Canada
United Kingdom
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Afghanistan
Åland Islands
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Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Postal / ZIP Code
Time Zone
How did you hear about Miss Dori Tutoring?
N/A
Referral
Google Search
Facebook
Yelp
NextDoor
Other
Referred by (if applicable)
STUDENT CONTACT INFORMATION:
Student's First Name
Last Name
Birth Date
Student's Cell (Required for Lesson Reminders)
Student's Gmail
Student's School Email
GOALS
Subjects (for tutoring)
Accounting
ACT / SAT
Advanced Functions (Gr 12)
Algebra 1
Algebra 2
AP Calculus AB
AP Calculus BC
AP Computer Science
AP PreCalculus
AP Statistics
Biology
Calculus
CFA
Chemistry
College/University Linear Algebra
Competition Math / Enrichment
Computer Programming
CS: C / C++
CS: Java
CS: Python
CSC
Data Management (Ontario)
Economics
Elementary Math (K-6)
English / Essay Writing
ESL
Finance
French
Functions & Applications (Gr 11)
Functions (Gr 11)
GED
General Homework Help
Geometry
High-School Math (9-10)
Middle-School Math (7-8)
Physics
PreCalculus
Reading (4-6)
Reading (K-3)
Science
SSAT - Elementary
SSAT - Middle
SSAT - Upper
Current Mark
Desired Mark %
IEP/Accommodations (extra time) and Learning Differences (Gifted, ADHD, etc.)
Has the student worked with a tutor in the past? Please describe.
Preferred Lesson Time(s) / Day(s)
Goals and Other Info
SCHOOL & ACADEMIC INFORMATION
School Name (or Homeschooled)
Academic Year (eg. Grade 9)
Type of School
Select
Public
Private
Catholic
Charter
Homeschool
Online
College
University
Other
French or English School? (Canada Only)
Select
English
French
French Immersion
Is Math Semestered or a Full-Year Course?
Select
First Semester Only
Second Semester Only
Full Year
Other
SCHOOL PLATFORM / LINKS
Textbook Name / Publisher / ISBN
Textbook Link
School Platform
BrightSpace / D2L
Google Classroom
OneNote
Schoology
Canvas
Moodle
My Math Lab
Other
School Platform Link
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