Student Intake Form

Welcome to Kaizen Education Services

Please complete the following information in preparation for our family meeting. We look forward to helping your child master their executive functioning skills to tackle life's many challenges. Thank you.

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

This is a long form, and your answers save automatically on this device as you go. You can close this page and come back later to pick up where you left off. It is fine to finish over two or three sittings.

Welcome back. We restored your saved answers below.

Prefer talking to typing? Tap the microphone beside any answer box and speak; we'll type it for you. Voice input is processed by your browser's built-in speech service.

Primary parent / guardian

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 child's 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 / Paediatrician Referral Friends and/or Family Referral Educator Referral Web Research Social Media Other

Other parents / guardians

Add any additional parents or guardians (step-parents included). Optional.

Family and home Is your family schedule busy?

Yes No

Regular family activities and commitments How often do you eat meals together?

Frequently Sometimes Rarely

How many siblings does your child have?

Languages spoken at home * Tell us about your child's living arrangement *

Please describe the living arrangement

If your child moves between homes, does anything change between them that would help us know? (different routines, access to materials or technology, quieter or busier environments, different bedtimes)

Student information

Complete this for your child. Open each section and answer what you can. If you are enrolling more than one child, use "Add another child" at the bottom.

Family meeting preferences

Your family meeting is held online and takes about 30 minutes. We walk you through the coaching plan, introduce the coach who will be assigned to your child, explain how weekly sessions run, and answer any questions you have.

Who will attend the family meeting? (students are welcome to attend but not essential) *

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.

Student Intake Form

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