College Circuit Parent Questionnaire

Student/Client Information

If you'd like a copy for your records, please print from your browser before clicking "Submit" at the end of this form.

I've already spoken to:
Patti Demoff
Peggy Saferstein
Suzanne Rubenstein
I haven't spoken to anyone yet

Student's Name
Student's Address
  City State Zip
   
Parent/Guardian 1 Name
Address
  City State Zip
   
Parent/Guardian 2 Name
Address
  City State Zip
Phones / Email  
Student:    
Home
Cell
Work
Fax
Email
Parent/Guardian 1:    
Home
Cell
Work
Fax
Email
Parent/Guardian 2:    
Home
Cell
Work
Fax
Email
Education & Occupations
Current School
  Grade Graduation Year
Student's Birthdate Age
Parent 1 College /
Grad School
Occupation
Parent 2 College /
Grad School
Occupation
Miscellaneous
Names, ages, and schools of brothers and sisters
Who referred you to us?
Student's Start Date

 


Parent Questionnaire

  1. Please use several adjectives that you believe would best describe your child.

  2. Is there a particular learning environment in which your child seems to thrive?

    Does poorly in?

  3. Are there any schools you would particularly like your son/daughter to consider? If so, why?

  4. Are there any schools or specific places you will not allow him/her to consider? If so, why?

  5. Will you need financial aid to attend? Yes No

    A private college ($60,000 plus expenses per year or more)
    An out of state public university ($30,000-60,000)
    An in state public university living on campus ($20,000-30,000)

  6. Has your child ever been identified as having a learning disability? ADD/ADHD or consulted a psychologist? Please explain.

  7. Has your child ever been suspended, expelled or put on probation since 9th grade?

  8. Is there anything else we should know about your child or you that would help us assist you in this process?

  9. Do you have any differences of opinion with your son/daughter/other parent regarding college? (location, expectations, cost, type of college, etc.)

  10. What is the most important to you in the college choice?
    (Rank 1-5, with 1 being the highest)

Fit
Affordability
Location
Perception (U.S. News Rank, "Name," Reputation)
Special Interest (academic, sport, LD Support, talent, etc.)