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Intake Form – Individual Coaching



Parent Name

Mobile Phone


Name of School

Have you tried other approaches to improve learning ability. Please explain

Have you / your child been diagnosed as ADD, ADHD, Dyslexic or any other learning difficulty? This does not affect my approach and is only for my records.

What would you like to achieve in working with us?

How will you know when you have the improvement you want? What result/evidence are you looking for?

How did you hear about The Learning Coach, please give specific details.

What are your son/daughters favorite things to do ? What is he/she motivated by ?

Do you fully understand that we will provide you with exact steps to take to get your desired result and the success of the program depends on you fully carrying out and completing each step.

Cancellation policy - Confirmed sessions that are not attended will be charged in full. Sessions cancelled with 24 hours notice with not be charged. - I understand the cancellation policy.

I consent to and request myself / my child to participate in the The Learning Coach program. By checking below I understand that I have the full responsibility for the health and safety of my child / myself. I will not hold The Learning Coach, eSports , Gulf Star or associated venues responsible for any loss, damage or injury to the participant or his or her belongings or claim for any injury or impairment the participant may incur during the duration of the Learning Coach sessions.