Student Intake Interview Form
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Interviewer: Intake date: [email protected]
2100 Blvd. des Laurentides, Vimont, Laval, Quebec. H7M 2R5 Tel: (450) 688-2933 ext. 3126 Fax: (450) 663-1290
Stud ent’s Intake In terview Date: Name: Address: Postal code *Birth date: * optional
/ Month
/ 19 Day
Year
Mother Tongue: Home tel.
Work tel.
Other:
Fax:
E-mail: How did you hear about The Learning Exchange?
SWL flyer
Literacy council:
Other:
TLE ad/promo/PSA
Friend/family
SWL office/personnel
Referral agency:
Background: Last grade completed at school: Where? What are your expectations/goals: Long-term goals:
Special skills/Interests:
Forms completed:
Membership card issued
Student’s availability
Everyday Situations
Placement
Notes/comments:
D. Brown/ 2009
2100 Blvd. des Laurentides, Vimont, Laval, Quebec. H7M 2R5 Tel: (450) 688-2933 ext. 3126 Fax: (450) 663-1290
Stud ent’s Intake In terview Date: Name: Address: Postal code *Birth date: * optional
/ Month
/ 19 Day
Year
Mother Tongue: Home tel.
Work tel.
Other:
Fax:
E-mail: How did you hear about The Learning Exchange?
SWL flyer
Literacy council:
Other:
TLE ad/promo/PSA
Friend/family
SWL office/personnel
Referral agency:
Background: Last grade completed at school: Where? What are your expectations/goals: Long-term goals:
Special skills/Interests:
Forms completed:
Membership card issued
Student’s availability
Everyday Situations
Placement
Notes/comments:
D. Brown/ 2009
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