Student Intake

Student Name

Age (lessons are for ages 6+)

School Grade (if applicable)

Lesson Length

Parent / Guardian Name (if student is a minor)

Email

Phone

Has the student taken piano lessons before?

No, complete beginner Self-taught / a little Yes, formal lessons

Years of Piano Study

Current Level (self-assessed)

Can the student read music?

Not yet Treble clef only Treble & bass clef Reads fluently

Method Books or Pieces Recently Studied

Other Instruments, Theory, or Exams

Instrument at Home

Acoustic piano Digital piano (88 weighted) Keyboard None yet

What are the student's goals for piano lessons?

Favorite styles, composers, or pieces

Practice Time Available Per Day

Preferred Lesson Days / Times

Anything else I should know? (learning needs, siblings, questions)