How would you like to be addressed?* First Name*
Last Name*
Phone Number*
Email*
Confirm Email*
Preferred Contact Method* Home Address*
How would you like to be addressed? First Name
Last Name
Phone Number
Email Address
Confirm Email Address
What would you like this contact to receive? Home Address (if different from Primary Contact)
How would you like to be addressed?* Emergency Contact First Name*
Emergency Contact Last Name*
Emergency Contact Relationship to Student* Emergency Contact Phone Number*
Email Address (Optional)
Additional Notes or Emergency Contacts for your Student (Optional)
Student First Name*
Student Last Name*
Student Preferred Name (if different from first name)
Student Phone Number (if applicable)
Student Email (if applicable)
Gender*
Student Pronouns (if applicable)
Additional Notes (Optional)
Please select the program(s) you are enrolling your student in. You may also select programs you are interested in.*
Which grade is your student currently in?* What is the name of your student's school?*
What type of school does your student attend?* Which city is your student's school located in?
School District, if known (Optional)
Grade Portal Name
Username
Password
Platform Name
Username
Password
Platform Name
Username
Password
How would your student describe themselves in 5 words or less?*
Your turn: How would you describe your student and their personality traits in 5 words or more?*
What are some of your student's favorite snacks and candy?*
What are some of your student's favorite things? (passions, shows, hobbies, characters, games, sports)*
What extracurricular activities is your student involved in?*
What are your student's strongest subjects?*
What subjects or skills are you hoping to strengthen with Ms. Amahni's support?*
If your student's last session was today, in what ways would you know this journey had been a success?*
Does your student have any known allergies? Write N/A if none.*
Does your student have any medical conditions Ms. Amahni should be aware of? Write N/A if none.*
Does your student have an IEP, 504 plan, or other documented accommodations? If yes, please describe the accommodations or relevant details.
Does your student have any documented or suspected learning differences or neurodivergence?
What does it look like when your student is frustrated?*
What does it look like when your student is tired or having a hard day?*
On a scale of 1 to 5, how comfortable is your student asking for help when they don't understand something?* What helps your student feel calm, settled, and focused?*
Days and times that work well for us*
Days and times that do not work for us*
How did you find Teach Me Ms. Amahni? Select all that apply.* If you're here because someone referred you, please share their name so I can thank them personally.
Is there anything else you would like Ms. Amahni to know before getting started?