Private School Counseling – Parent Survey

Student Details

Student Name *

First

Last

School Name *

High School Graduation Year *

Moxie Counselor *

How did you hear about Moxie? *

Who or how? *

We thank our referrals, so please type in the name of the person or organization.

Parent Details

Parent/Guardian 1 *

First

Last

Relationship to Student *

Primary phone number *

Phone type *

Secondary phone number

Phone type

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation/Title

Name of organization/company

Education

Please include all institutions, degrees earned, and years when awarded

Community involvement

Add Parent/Guardian 2? *

Parent/Guardian 2 *

First

Last

Relationship to Student *

Primary phone number *

Phone type *

Secondary phone number

Phone type

Email *

Same street address as Parent/Guardian 1?

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation/Title

Name of organization/company

Education

Please include all institutions, degrees earned, and years when awarded

Community involvement

Student resides with *

Does your student have any siblings? *

Name(s) and grade(s) of student's siblings *

Please write three words that come to mind when you think about your child. *

Want to elaborate? Please do!

Please describe in your own view how your child is doing academically. *

Please describe in your own view how your child is doing socially/emotionally?

Please describe one or more of your child's noteworthy moments: accomplishments, improvements, developments, milestones etc.

What is something you wish your child already knew about themselves or how the world works? *

Are there any circumstances (e.g., medical, psychological, family-related, socio-emotional, school transfer, substance abuse, or disciplinary history) that have affected your child's academic, social, or personal experience? *

Please explain. *

To you, which of the following are important factors you will consider during your child's admissions process? *

Prestige
Cost
Location
School Size
Particular academic offerings
Performing arts/fine arts
Proximity to home
Climate
Geographic region
School spirit
Athletic programs/recruitment
Particular clubs/organizations

What, if any, are concerns you have about the admissions process?

Standardized testing
Admissibility (“getting in”)
Role of parent
Application essays
Planning school visits
Extra-curriculars
Athletic recruitment
Anxiety/stress
Time management of the process
Finding the best fit
Letters of recommendation
Summer planning

For both questions above, feel free to explain your choices here:

Are there any specific schools that are already important to you or your child?

To what extent is cost a factor in college selection for your child? *

Not a consideration
Somewhat a consideration
An overriding factor

Please explain *

Is there anything else you want to share before the first session?