Family Intake Form

Welcome to Kaizen Education Services

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

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

Who are you completing this intake for?

Myself, as an adult

Use the adult intake form if you are completing this for yourself, including if you are an adult student.

Continue here if you are completing an intake for your child, seeking parent coaching, or both.

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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 *

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

Who is this intake for?

My child or children Me, as the parent Both

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

Other parents / guardians

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

Life at home Where do you see the most friction at home? *

Mornings Homework Screens Transitions Bedtime Sibling conflict Other

Please describe the other friction point

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.

About you

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

What brings you

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? *

Your parenting context

Ages of your kids

Co-parenting or household arrangement, if it affects routines Anything about your work or household load a coach should understand?

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

One more thing, for you Supporting a kid with executive functioning challenges takes a lot. Which of these feel true for you?

Staying organized myself Keeping my own routines going Staying calm during homework battles Managing my own overwhelm Following through on my own plans None of these

Kaizen also coaches parents. Want to hear about it?

Yes, tell me now Maybe later No thanks

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.

Family Intake Form

Who are you completing this intake for?

What brings you

Your parenting context

Your history

Strengths and motivation

Coaching fit

Consents

Almost there