Registration

404.618.3132 office

Circle Service of Interest

Educational Advocacy                                           Customized Tutoring                                    Home Behavior Management Intervention

Print Rich Infused Home                                       Educational Planning                                    *Diagnostic Educational Assessments

*Information in this document is protected by HIPAA privacy laws and should be handled accordingly.

Application

​

Home Address

Work Address

Background Information

Child Resides With:

Level of Education: GED, High School Diploma, Graduate, or Post Graduate

Level of Education: GED, High School Diploma, Graduate, or Post Graduate

Names of Sibling(s): (Full, Half and Step)

Names of Sibling(s): (Full, Half and Step)

Pregnancy, Birth, & Early Development

Pregnancy, Birth, & Early Development

Was the birth full term? 

Was the birth full term? 

Check all that apply:

Check all that apply:

Check all that apply:

Was mother under doctor's care?

Developmental Milestones 

Place the age child met developmental milestone:

Medical History

Check all that apply:

Balance Problems

Emotional Problems

High Fevers

Medication

Mental Illness

Convulsions

Ear Infections

Head Injuries

Seizures

Allergies

Vision Difficulties

Diabetes

Glasses

Accidents

Asthma

Frequent Headaches

Social/Emotional Development

Check all that apply:

Happy Child

Demands excessive attention

Overly dependent on others

Wets bed

Plays well with other children

Plays well with other children

Tries to control others

Lacks motivation

Compulsive with order

Overly anxious to please

Poor self-control

Lazy

Fearful

Exhibits uncooperative attitude

Limited friends

Aggressive

Shy, withdrawn

Moody

Friendly

Sad

Easily frustrated

Acts younger than age

Affectionate to family

Daydreams often

Restless

false

Jealous

School Information

Check all that apply:

School Information

Special Education (IEP)

Early Intervention Services (EIP with SST)

Enrichment or Discovery Program

Academic Difficulties

Undesired Conduct

Scholarships

Retention of Grade(s)

Lack of School Support with Staff

Placement Assessments

Short Attention Span

College Planning

Counseling

Grades

Learner Profile

Answer questions about the text that is not directly written stated (Inference)

Solve problems involving addition and subtraction without regrouping

Solve problems involving multiplication, division, decimals and fractions

Solve problems involving addition and subtraction with regrouping

Solve problems involving integers, ration & proportion, equations

Interpret data through charts, graphs and illustrations to solve problems

Student Interest Survey

What is your favorite class or activity in school? Why?

What is your least favorite class or activity in school? Why?

Which school subject is most challenging to you?

Share with me a lesson or activity in school you enjoyed

Do you like to work in groups, alone,or in large groups? Why?

What do you want to do after high school?

What job profession interests you? Why?

Do you have a special interest or talent? If so, what is it?

Tell me about a past accomplishment that made you feel proud of yourself

Signature

I agree to the terms and conditions 

Your content has been submitted

"Our company exists to meet the educational needs of families and children through quality Educational Advocacy, Educational Assessments, and Educational Planning. In addition, we specialize in Customized Tutoring, Print Rich Infused Homes, and Home Behavior Management Intervention services. Through these services, we enrich and close the academic achievement gaps of the learner while equipping and empowering the family."

Monetia Hollie