PERSONAL INFORMATION

First Name

Last Name

Address

City

Postal Code

Daytime Phone  (and/or) Cell Phone 

Email address 

Profession

OccupationEmployer
City Country

Referral
How did you find out about these services?

Prior Training
Do you have prior training in Brain Gym®, specialized kinesiology or other movement based or brain-based programs? Please explain.

Work Setting
These questions pertain to the target group for the Braingym Plus program:

If you work with more than one group, identify each group by a name or number. This will allow us to develop programs specific to each group.

Please describe your work environment by answering the questions below. Include any pertinent information about the population you are working with.

For each group, please include the following:
o size of group
o ages
o frequency of meetings
o purpose of meetings
o challenges of each group

NB: If you are a schoolteacher, simply give the context (grade level and/or subject matter you teach as well as age of students).

• What are the group members’ expectations regarding the work you are doing with them?

• How will the addition of brain-based movements be perceived by your group members? Your employer?

• What are your goals/objectives regarding taking the program Braingym Plus?

Is there anything more you would like to share?