Optimized Learning Intake Form

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Name
First Name
Last Name
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Email
example@example.com
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Primary Language(s) Spoken
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When learning something new, which of these feels most natural to you?(Select all that apply.)
“I need to see examples, diagrams, or visuals to understand.”
“I need to hear clear explanations or discussions to grasp it.”
“I need to try it out myself or interact with it physically.”
“I use a mix of these approaches depending on the situation.”
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When you struggle to understand something, what do you do first?(Select your natural instinct.)
“I try to picture it in my mind or look for visual aids.”
“I repeat the information or ask someone to explain it again.”
“I take notes, move around, or try to practice it physically.”
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Can you describe a recent situation where you felt stuck while learning? What happened, and how did you respond?
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If learning were a journey, what kind of journey would it be? Are you climbing a mountain, walking through a forest, or something else?
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Have you ever said or thought any of the following?(Check any that apply.)
“I’ve never been good at learning.”
“I always struggle with new information.”
“If a teacher is boring, I can’t focus.”
“I know I’m bad at this subject.”
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What’s your earliest memory of learning something new? How did that experience shape how you feel about learning today?
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When you feel stuck or confused while learning, what’s the first emotion that comes up for you?
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Think of something you recently learned. What do you notice first when recalling it?
“A mental image or visual details.”
“The sound of someone explaining it or key phrases.”
“How it felt when I experienced it or practiced it.”
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When remembering a past event, what comes to mind first?
“What I saw, like colors, faces, or settings.”
“Sounds, voices, or words I heard.”
“The way I felt at that moment.”
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If someone were to describe your learning style, what do you think they’d say?
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What kind of environment do you learn best in?
Absolute quiet, so I can focus.
Background noise or music helps me concentrate.
Moving around or taking notes helps me retain better.
Other
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If you could design the perfect learning environment for yourself, what would it look like? What would it feel like?
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What would success in this consultation look like for you?(Select all that apply.)
Gaining new techniques for easier learning.
Discovering what learning style works best for me.
Overcoming a specific frustration I have with.
Other
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What’s one thing you wish were different about how you learn?
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What emotions arise when you think about learning?
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If you could describe your relationship with learning as a relationship with a person, what would it be like?
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Is there anything about how you learn that you’ve never shared with anyone before? If so, what is it?
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