Educational Services Preliminary Survey

STUDENT INFORMATION

Student Name

First Name

Date of Birth

Grade-Level

Type of School

(e.g., public, private, homeschooling)

Start Date:

Short Term

(End) Long Term

PARENT/GUARDIAN INFORMATION

Full Name

Relationship

Address

Apt

City

State

Zip Code

Phone Number (Cell)

Email*

Other Parent /Alternate Contact

Full Name (Last First)

Relationship

Address

Apt

City

State

Zip Code

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Educational Services Preliminary Survey Cont.

STUDENT INFORMATION

All students enrolled will undergo pre-assessments before commencing academic support.

Subject Areas Being Requested ( Please check all that apply):

Reading_ Remedial_or Acceleration_ Math _ Remedial _or Acceleration_

Writing_ Remedial_ or Acceleration___

Learning Goals/ Expections

Current Academic Performance Level

Reading

Writing

Math

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Educational Therapy Enrollment Form

At Adesuwa Academy, we are dedicated to reducing the stress of school journey. We equip students to help them overcome academic challenges and reach their fullest potential.Providing personalized plans and utilizing evidence-based strategies, to address students’unique needs reflect our commitment to supporting flourishing students. We provide targeted assistance for individuals with diverse learning needs, including but not limited to executive function challenges, learning disabilities, ADHD, autism spectrum disorder, and giftedness.

We aim to foster independence, self-confidence, and academic resilience by addressing each student's unique strengths and needs. Through collaborative goal setting, we implement a strength-based approach to help students develop essential skills such as planning, organizing, time management, and self-advocacy.

We implement a holistic approach to serving students by partnering with families, schools, and other professionals to create a support system, ensuring every learner has the tools they need to succeed in their educational journey and beyond. At Adesuwa Academy, we believe that with the right support, every student can succeed.

CONTACT
Email: Info@adesuwaacademy.org

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ADESUWA ACADEMY PARENT QUESTIONNAIRE

Thank you for taking the time to complete this intake questionnaire. The information you provide will help us better understand the student’s strengths, challenges, and unique needs. This ensures we can develop a personalized plan to support their learning journey. All responses will be kept confidential and used solely to tailor our services to your child’s goals.

Parent Name

Date

Parent Name

Date

Address

Phone

1. What is the student’s name, age, and grade level?

2. What type of school does the student attend (e.g., public, private, charter homeschool)?

3. What challenges or concerns led you to seek educational therapy?

4. What specific academic subjects or skills is the student struggling with? Explain

5. Are there behavioral, emotional, or social issues that might affect learning?

6. What are the student’s academic interests?

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7. Has the student been diagnosed with a learning difference, ADHD, autism, or other conditions? If yes, state impact on learning and behavior.

8. Has the student undergone any formal evaluations (e.g., psychoeducational testing, neuropsychological assessments)? Explain

9. Which of the following does Student have? IEP, ISP, 504 Plan, or other : Please state eligibility

10. What specific outcomes are you hoping for student to achieve through educational therapy?

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11. How do you envision your involvement as a parent/guardian in this process?

12. List all the subjects student need support in, in the order of difficulties.

13. What subject (s) do you want student’s learning accelerated in?

14. How do you envision your involvement as a parent/guardian in this process?

Additional Comments

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RELEASE OF INFORMATION

Authorization to Release Confidential Information

I Name of Parent or Client if over 18

hereby authorize

Adesuwa Academy to release and/or obtain confidential information as specified below regarding:

Student’s Name

Date of Birth

Information to Be Released/Obtained (Check all that apply):

Educational records (e.g., report cards, IEP, 504 Plan)

Psychoeducational or neuropsychological evaluations

Communication with school personnel (e.g., teachers, counselors)

Other

Purpose of Disclosure

Coordination and Development of academic and intervention goals

Communication with school/other service providers

Other

Parties Authorized to Share Information

1. Releasing Information To/Obtaining Information From:

Name of Individual/Organization

Role/Title (e.g., teacher, evaluator):

Phone

2. Additional Party (if applicable):

Name of Individual/Organization

Role/Title

Phone

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Duration of Authorization

This authorization is valid:

From the date of signature until (specific date):

Until the end of services provided by Adesuwa Acad

Specific Date

Rights and Revocation

I understand that I have the right to revoke this authorization at any time by providing written notice to Adesuwa Academy.
I understand that the revocation will not apply to information already released or actions already taken based on this authorization.
I understand that refusing to sign this form may limit certain services or communication but will not affect eligibility for educational therapy services.

Confidentiality Notice

I understand that the information disclosed may be protected by federal and state laws, including but not limited to the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA). The receiving party is required to keep the information confidential and use it solely for the authorized purpose.

Signature of Parent/Guardian/Client (if over 18):

Date

Printed Name of Parent/Guardian/Client:

Relationship to Student (if applicable):

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Enrollment Form

STUDENT INFORMATION

Student Last Name

First Name

Date of Birth

PARENT/GUARDIAN INFORMATION

Full Name

Relationship

Address

Apt

City

State

Zip Code

Phone Number (work)

(Cell)

E-mail:

OTHER PARENT OR GUARDIAN

Full Name

Relationship

Address

Apt

City

State

Zip Code

Full Name

Relationship

Address

Apt

City

State

Zip Code

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TUITION AND FEE PAYMENTS

Hourly Rate

Total Number of Hours

Total Payment

POLICIES AND BILLING

Scheduling and Cancellation

To ensure clarity and a successful partnership, we have outlined our policies and billing practices below. Please read carefully and don’t hesitate to contact us with any questions.

Scheduling and Appointments

Session Length: Sessions are typically 1 hour long unless otherwise agreed upon.

Cancellations/Rescheduling: We require at least 24 hours' notice to cancel or reschedule a session.
Cancellations made with less than 24 hours' notice may result in a charge for the full session. Exceptions will be made for emergencies at the discretion of the therapist.

Late Arrivals: If you arrive late, the session will still end at the scheduled time, and you will be charged for the full session.

Three-Day Cancellation: An applicant who provides written cancellation notice within three calendar days of signing an enrollment agreement/payment, is entitled to a full refund if instruction has not commenced. No later than 10 days after receiving the cancellation notice, the academy shall provide a 100% refund.

All services offered before cancelation will attract an hourly rate of

(As agreed)

Signature of Parent/Guardian/Client (if over 18):

Date

Printed Name of Parent/Guardian/Client:

Relationship to Student (if applicable):

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Billing and Payment Policies

Rates:

Initial Intake/Assessment Session:

Regular Educational Therapy Sessions:

Per Hr. (Discount- Re assess in 3-6 months)

Consultation

Detailed Progress Report Report $

Writen 1 page Communication Support to assist in constructing a request/concern letter or email/ light review of information

One Follow-up free or addition charges.

Meeting Attendance : $

per hour

Reviewing IEP and documents in preparation for a meeting $

Communication

Outside Session Communication: Brief communications (e.g., emails or phone calls under 15 minutes) are included in the service. Longer communications may be billed at $_

per

minutes. Five to ten minutes will be set aside to brief parent about the session, as needed

Calls over 15 min. equals half an hour fee $

Long Emails requiring going back and forth will attract 30 min. to an hour fee

Payment Methods: We accept payment via:

Credit/Debit Card

Check

Other

There is a 3.5% third party service fee for credit card/ debit card payments

Billing Cycle: Payment is due at the begining of the month, before service, unless a prior
arrangement has been made.

Late Payments: Payments not received within

days of the due date will incur a late fee of $

Returned Checks: A fee of $

will be charged for any returned checks.

Insurance: Educational therapy services are typically not covered by insurance. However, we can provide a detailed invoice for you to submit to your insurance company for possible reimbursement.

CANCELLATION AND REFUND POLICY

Confidentiality

All client information is strictly confidential and will not be shared without written consent, except in cases required by law (e.g., suspected abuse, harm to self or others).

Response Time: We strive to respond to all emails and calls within 1-2 business days.

Please sign to acknowledge that you have read and understand the policies

Name

Signature

Date

Survey Form

Educational Services Preliminary Survey

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Other Parent /Alternate Contact

Educational Services Preliminary Survey Cont.

STUDENT INFORMATION

All students enrolled will undergo pre-assessments before commencing academic support.

Subject Areas Being Requested ( Please check all that apply):

Reading_ Remedial_or Acceleration_ Math _ Remedial _or Acceleration_

Writing_ Remedial_ or Acceleration___

Current Academic Performance Level

Educational Therapy Enrollment Form

ADESUWA ACADEMY PARENT QUESTIONNAIRE

RELEASE OF INFORMATION

Authorization to Release Confidential Information

Enrollment Form

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

OTHER PARENT OR GUARDIAN

TUITION AND FEE PAYMENTS

POLICIES AND BILLING

Billing and Payment Policies

Communication

CANCELLATION AND REFUND POLICY

Confidentiality

© 2025 Adesuwa Academy. All Rights Reserved.

Educational Services Preliminary Survey

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Other Parent /Alternate Contact

Educational Services Preliminary Survey Cont.

STUDENT INFORMATION

All students enrolled will undergo pre-assessments before commencing academic support.

Subject Areas Being Requested ( Please check all that apply):

Reading___ Remedial___or Acceleration___ Math ___ Remedial ___or Acceleration___

Writing___ Remedial___ or Acceleration___

Current Academic Performance Level

Educational Therapy Enrollment Form

ADESUWA ACADEMY PARENT QUESTIONNAIRE

RELEASE OF INFORMATION

Authorization to Release Confidential Information

Enrollment Form

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

OTHER PARENT OR GUARDIAN

TUITION AND FEE PAYMENTS

POLICIES AND BILLING

Billing and Payment Policies

Communication

CANCELLATION AND REFUND POLICY

Confidentiality

© 2025 Adesuwa Academy. All Rights Reserved.

Reading_ Remedial_or Acceleration_ Math _ Remedial _or Acceleration_

Writing_ Remedial_ or Acceleration___