Adult Intake Form

Welcome to Kaizen Education Services

Please complete the following information so we can prepare for your coaching program and make your first session useful. Thank you.

Fields marked * are required. Anything else you skip we will cover together in your welcome meeting.

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About you

First name *

Last name *

Your email * Your phone number *

Best number to reach you at. Choose the country the number is in.

City of residence *

Country of residence *

I agree to receive communications from Kaizen Education Services about my coaching program, including scheduling, resources, and occasional tips and event invitations. You can unsubscribe from non-essential emails anytime. How did you hear about Kaizen Education Services? *

Psychologist Referral Doctor Referral Friends and/or Family Referral Educator Referral Web Research Social Media Other

What brings you

These questions help us match you with the right coach and make your first session useful. There are no wrong answers.

What do you want coaching help with, in your own words? * If this worked, what would be different six months from now? * What are your top three day-to-day challenges? * What have you already tried, and what happened? *

Work and life What is your current work or study situation? * Where do executive functioning challenges cost you the most? *

Deadlines and deliverables Email and admin Money and bills Home admin and paperwork Planning and prioritizing Getting started on tasks Finishing what I start Time awareness and being on time Other

Please describe where else it costs you

Who is in your support circle?

Spouse or partner Add my spouse or partner to our Kaizen household.

Kaizen will create or uniquely match a limited non-marketing contact and link it to you. This form will not subscribe them to messages, marketing, opportunities, or automated follow-up.

Spouse or partner's full name *

Email

Phone

Please provide at least one: email or phone.

Your history

Share only what you are comfortable with. Everything here is optional.

Prior coaching, therapy, or assessments you would like us to know about Any diagnosis you choose to share Prefer not to say Medications, if relevant Prefer not to say Anything else that affects how you want to be coached?

Strengths and motivation What are you good at? * What motivates you? What do you do to recharge?

Coaching fit What qualities in a coach do you work best with? How do you usually respond to feedback or correction? How ready are you to try new systems and do the work between sessions? *

Ready and willing Somewhat hesitant Honestly not sure yet

Consents Do you consent to Kaizen coaches consulting our educational psychologist, if required, about your program? *

Yes No

May we reference the coaching, therapy, or assessment history you shared?

Yes No

Your welcome meeting

Your welcome meeting is held online and takes about 30 minutes. We walk you through your coaching plan, introduce your coach, explain how weekly sessions run, and answer any questions you have.

Preferred session format going forward *

In person Online Hybrid

Your time zone *

We detected this from your device, so please change it if it is not right. Our coaching runs out of Calgary (Mountain Time), and we will show you what each option below looks like where you are.

Day and time options that usually work for weekly sessions *

Please give us at least two. A third helps us find a fit faster, especially outside Mountain Time.

Option 1: day *

Option 1: time (Mountain) *

Option 2: day *

Option 2: time (Mountain) *

Option 3: day (optional)

Option 3: time (Mountain)

Empowering Brains for Learning and Life

Kaizen Education Services, Calgary, Alberta, Canada.
Educational coaching, not medical or clinical care.

Adult Intake Form

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