Core Service Tutoring
Spotlight Service Tutoring
Co-Pilot Service Tutoring
(What Service Is Right?)
Handwriting / Keyboarding
Executive Functions Coaching (PEG)
Educational Testing and Evaluation
ISEE / HSPT / SSAT Prep
College Essay Writing Guidance
Friends of QWERTY
QWERTY Education Services
Form Test – Educational Testing Information Form
Educational Testing Information Form
Name of Parent or Guardian #1:
Name of Parent or Guardian #2 (Optional):
Primary Phone Number:
Address Line 2
ZIP / Postal Code
Mobile Phone (Parent 1):
Mobile Phone (Parent 2):
Email Address (Parent 1):
Email Address (Parent 2):
Student Mobile Phone (optional):
Student Email Address (optional):
Please indicate a contact preference order (1, 2, 3, etc.) for all phone numbers, home and/or mobile:
Mobile Phone (Parent 1)
Mobile Phone (Parent 2)
Is email a reliable way to communicate with you?
May we contact you via email with QWERTY-related news? (2-3 times yearly)
Do you use Facebook?
Do you use Nextdoor?
Have you ever written a Yelp! review?
Alternate contact(s) in case of emergency (name, relationship, contact phone #):
Are there any medical concerns to be aware of while this student is working at QWERTY (possible diabetic reaction, seizures, allergies, etc.)?
Special instructions in the event of a medical or other emergency:
Please confirm your EMAIL address for billing (PDF format):
(Write "Paper" if you prefer bills sent via USPS to your home address):
Payment is due during the month in which your PDF invoice is received by mail or email. We encourage email to save paper. A non-optional late fee of 1.5% will be added for payments received after the due date. Payment 2 months late are subject to an additional 1.5% late fee, and 3 months late will be subject to an additional 1.5% late fee. Your prompt payment helps simplify our accounting and is sincerely appreciated.
Educational Testing Fees are determined by total number of hours testing, scoring, and writing the report. The Psychologist rate is $220/hr and the Learning Specialist rate is $170/hr. An additional Administrative Testing Fee is also added ($200 for a Psychoeducational Evaluation, $350 for a Comprehensive Assessment) that covers materials, billing and other costs.
Cognitive Testing "IQ" without Analysis $500.
Scheduling and Cancellation:
Please phone as far in advance as possible if you are unable to keep a scheduled appointment, providing the reason for the absence. You will be billed for one hour of time for appointments missed without
Since holiday schedules vary in different schools, it is your responsibility to confirm your schedule for those days.
Please type your full name to certify that you have read and understand the above.
How did you hear about us?
Did you learn about us from another past or present family that has worked with us?
Were you referred to QWERTY by a professional? (Teacher/Education Professional/Other).
What is this person's profession? (Teacher/Educational Professional/Other).
Did you hear about QWERTY through a Website or Social Media? (please select all that apply)
Other Search Engine
Search words used (if known):
Other Referral Source (please specify):
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