Pathways to Prosperity

Family Intake Form

Please complete this form as thoroughly as possible so that Sheila can make the best use of your consultation time together. All information is kept strictly confidential.

Student Information

Student's Full Name *

Date of Birth *

Age *

Current School *

Grade *

Student Email *

Social Media Handles

Special Pathway in High School

Cumulative GPA *

Standardized Test Scores (if applicable)

PSAT Score

SAT Score

ACT Score

Extracurricular Activities

Sports

Music

Arts

Other Activities / Clubs

Community Involvement

Community Volunteering / Service Activities

Required Community Service Hours (if applicable)

Parent / Guardian 1

Full Name *

Relationship

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Date of Birth

Job Title

Employer Name

Employer Phone

Employer Email

Committed to paying for school? *

YesNoPartially

Parent / Guardian 2 / Stepparent (if applicable)

Full Name *

Relationship

Street Address

City

State

ZIP Code

Phone Number

Email Address

Date of Birth

Job Title

Employer Name

Employer Phone

Employer Email

Committed to paying for school?

YesNoPartially

Custodial Information

Is there a custodial parent arrangement?

yesno

All information provided is strictly confidential and will only be used by Sheila Coleman-Castells for educational counseling purposes.