College Counseling Intake Form

Student's Full Name *

First

Last

Preferred Name

Student's Preferred Pronouns *

Date of Birth

Student's Email *

Student's Cell Phone *

Current School *

Schools Previously Attended

Please include name of school(s) and grades attended.

Is the student an American Citizen?

Has the student ever completed educational or psychological testing?

If applicable, please share more about your child's learning differences and/or any current or past diagnoses.