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Run: Adult Literacy or ESL Learner Intake and Assessment

An intake and placement form for adult literacy and ESL programs that captures learner background, goals, consent, and assessment results in one place. Use i...

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Program Notice and Consent

Consent to collect and use this information for program intake and placement (required)

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.

Yes No N/A

Preferred contact method (required)

May we leave a voicemail? (required)

May we send text messages? (required)

Learner Profile

Learner name (required)

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 (required)

Country where most education was completed

Primary language spoken at home (required)

Learning Goals and Support Needs

What are your main learning goals? (required)

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? (required)

Please describe the accommodation needed (required)

Examples: large print, extra time, interpreter, hearing support, mobility access, or other reasonable accommodation.

Placement Assessment Results

Assessment date (required)

Assessor name (required)

Assessment type (required)

Recommended placement level (required)

Assessment summary (required)

Summarize observed strengths, support needs, and placement rationale.

Tutor Assignment and Follow-Up

Tutor match preference

Is a referral needed? (required)

Referral details (required)

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.

Get your results

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Email (required)

Your name (optional)

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