You are on page 1of 2

Client Registration Form

Client Information
Name:

Address:

Date of birth:
Cell phone:
Email:
Current place of study:

Program of study:

Have you ever received a diagnosis? If yes, please specify.

What are your strengths and academic goals?

Which areas require improvement and/or skill building?

Emergency Contact Information


Emergency Contact Name

Relationship

Phone #

How did you find out about Brightside Learning?

173 Cartier #103, Pointe-Claire, Quebec H9S 4R9514-242-5162 | robin@brightsidelearning.com | www.brightsidelearning.com

Brightside Learnings Agreement for Services


Brightside Learning is a centre that offers academic & personal support to struggling students. ADHD
and Academic Coaching works to address why students are struggling so that they can eventually learn
on their own. Students meet with a Learning Coach on a weekly basis to develop personalized
strategies for organization, time management, study skills, following routines, managing stress, selfregulation & improving academic skills. They also learn skills for note-taking, goal setting, preparing for
tests, and managing anxieties related to school. Please note that all coaching sessions include unlimited
follow-up by email and/or text message.
New clients meet their coach during a 50-minute Initial Consultation where they will work together to
set both short term and long term goals, as well as discuss areas of strength and where improvements
need to be made. This session also measures client suitability for coaching. After the initial consultation,
coaching sessions take place on a weekly basis in a regularly scheduled time slot, in either 30-minute or
50-minute sessions.
ATTENDANCE & LATENESS

In order to enable progress and success, it is crucial for clients to commit to regular weekly
attendance for the duration of their academic semester. Clients are also expected to arrive on time to
their sessions; please note that sessions cannot be extended to accommodate late arrivals.
CANCELLATIONS

Notice of 24 hours must be provided for cancellations, unless you are sick or there is an emergency. In
these rare cases, please let us know about the cancellation as soon as possible by emailing
robin@brightsidelearning.com or calling 514-242-5162. Additionally, if less than 24 hours notice is
provided, you are responsible to pay an administrative fee of $35.00 that is due at the beginning of
your next session. Please note that if frequent cancellations are recorded, a re-evaluation of your
commitment to coaching and discussion about your weekly time slot will ensue.
PAYMENTS FOR SESSIONS

The cost of the Initial Consultation is $85.00 and payment is accepted at the end of the session.
The cost of the 30-minute weekly session is $40.00 and the cost of the 50-minute weekly session
is $65.00; payment is due at the beginning of the session.
Insurance receipts for naturopath services are provided upon payment; please contact your
insurance provider to verify your eligibility.
Accepted methods of payment are cash, cheque or credit card (Visa, MasterCard or Amex)
All cheques should be made out to Brightside Learning; please note that insufficient funds for
cheques (NSF) will incur a $15.00 administrative fee and all future sessions will be suspended
until the payment has been rectified.
I have read Brightside Learnings Coaching Agreement and agree to its terms.

Client signature: _______________________________

Date: ___________________________________

173 Cartier #103, Pointe-Claire, Quebec H9S 4R9 | 514-242-5162 | robin@brightsidelearning.com |www.brightsidelearning.com