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.

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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 *

Yes, sign me up for email tips, resources and early access to workshops and events. We won't spam you and you can unsubscribe 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 Preferred family meeting type *

The family meeting is typically 30 minutes. We go over the coaching plan and which coach will be assigned, and answer any additional questions you might have.

In person Online Either works

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

Preferred session format going forward *

In person Online Hybrid

Two day-and-time options that usually work for weekly sessions *

Session times are shown in Mountain Time (Calgary). Please choose times that work for you in that zone.

Option 1: day *

Option 1: time (Mountain) *

Option 2: day *

Option 2: time (Mountain) *

Empowering Brains for Learning and Life

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