Student Intake Form

Welcome to Kaizen Education Services

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

Answer what you can; anything you skip we will cover together in the family meeting.

Primary parent / guardian

First name *

Last name *

Your email * Your phone number *

Best number to reach you at.

Your date of birth

Age

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 Referral Web Research Social Media Educator Referral 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

Siblings (names and ages) Who is the most organized at home, and is organization emphasized in your house? Languages spoken at home

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 meeting type

In person Online Either works

Who will attend the family meeting? Preferred session format going forward

In person Online Hybrid

Two possible days and time windows that usually work for weekly sessions

Empowering Brains for Learning and Life

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