Adult Literacy or ESL Learner Intake and Assessment

Intake form for adult literacy and ESL programs to capture education history, language background, learning goals, and placement assessment results for tutor assignment and level placement.

Program Notice and Consent

• Consent to collect and use this information for program intake and placement
  By checking this box, the learner agrees that the program may use the information provided to assess needs, determine placement, and contact the learner about services. Do not include sensitive personal details unless needed for program delivery.
• Preferred contact method
• May we leave a voicemail?
• May we send text messages?

Learner Profile

• Learner name
• Date of birth
  Optional. Collect only if needed for age-based program eligibility or reporting.
• Phone number
• Email address
• Preferred pronouns

Education and Language Background

• Highest level of education completed
• Country where most education was completed
• Primary language spoken at home
• Other languages spoken or read
• How often do you use English in daily life?

Learning Goals and Support Needs

• What are your main learning goals?
• Tell us more about your goals
  Optional. Use this to describe specific tasks, goals, or deadlines.
• Preferred learning format
• Do you need any learning accommodations?
• Please describe the accommodation needed
  Examples: large print, extra time, interpreter, hearing support, mobility access, or other reasonable accommodation.

Placement Assessment Results

• Assessment date
• Assessor name
• Assessment type
• Recommended placement level
• Assessment summary
  Summarize observed strengths, support needs, and placement rationale.

Tutor Assignment and Follow-Up

• Tutor match preference
• Is a referral needed?
• Referral details
  Use only if the learner should be connected to another service, class, or support resource.
• Next contact date
• Coordinator notes
  Internal notes for assignment, scheduling, or follow-up. Avoid unnecessary PII.