Student Questionnaire

Name

Age

School Name & Grade

Parent's Name

Phone

Address

How do you feel about the following:

Very Good

Good

Fair

Poor

Very Poor

Family

Friends

School

Extra Curricular

Self-Esteem

Your Life

Estimate screen time per day/week?

What do you want to accomplish with tutoring?

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20