Jewel Minds Parent Intake & Session Booking Form

Jewel Minds Parent Intake & Session Booking Form

Please complete this confidential form so we can learn about your child’s needs and match you with the right support. Once submitted, you’ll receive next steps and scheduling options.
Welcome to Jewel Minds! We’re excited to partner with your family. Our mission is to empower students through strengths-based, SPED-informed academic support and mindset coaching. Please complete this form so we can learn about your child’s needs and match you with the right support. All information is confidential and used only to provide the best experience for your family.
SECTION 1 — Parent/Guardian Information
Full Name*

First NameLast Name
Email Address*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Preferred Method of Contact*

EmailPhoneText
Best Time to Reach You*
Relationship to Student*
SECTION 2 — Student Information
Student Name*
Student Grade*
School (Optional)
What are your child’s strengths?*
What challenges or goals would you like support with?*
Does your child have an IEP or 504 Plan? (Optional)

YesNoPrefer not to say
What supports have worked well in the past?*
SECTION 3 — Service Interest
What type of support are you interested in?*

Literacy SupportExecutive FunctioningHomework CoachingMindset & Confidence CoachingSPED‑Aligned Academic SupportTest PrepSocial‑Emotional Learning SupportMathScienceOther (please specify)
Are you looking for short‑term or long‑term support?*

Short‑term (4–8 weeks)Long‑term (3+ months)Not sure yet
Are you interested in 1:1, small group, or both?*

1:1Small GroupBothNot sure yet
SECTION 4 — Scheduling Preferences
Preferred Session Format*

VirtualIn‑person (if available)Either
Preferred Days*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Time Windows*

MorningAfternoonEvening
When would you like to start?*

ASAPWithin 1–2 weeksNext monthOther
Do you need a consistent weekly time or flexible scheduling?*

Consistent weekly timeFlexible schedulingNot sure yet
SECTION 5 — Session Logistics
Preferred Session Length*

45 minutes60 minutesNot sure
How many sessions per week are you considering?*

1 session per week2 sessions per week3+ sessions per weekNot sure yet
Billing Preference*

Recurring monthly billingPay‑as‑you‑goNot sure yet
SECTION 6 — Technology & Access
What device will your child use for sessions?*

LaptopTabletPhoneMultiple devicesNot sure
Do you have reliable internet access?*

YesMostlyNo
Does your child need support navigating online platforms?*

YesNoSometimes
SECTION 7 — Additional Notes
Anything else you’d like us to know?
What does success look like for your child in the next 3 months?
How did you hear about Jewel Minds?
Optional Upload: IEP Snapshot, Teacher Notes, or Assessments

Cancelof
SECTION 8 — Consent & Policies
Please confirm the following:*

I agree to be contacted by Jewel Minds regarding services.I understand that completing this form does not guarantee a specific time slot.I understand that all information shared is confidential.I have reviewed the privacy policy.
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Jewel Minds Parent Intake & Session Booking Form

SECTION 1 — Parent/Guardian Information

SECTION 2 — Student Information

SECTION 3 — Service Interest

SECTION 4 — Scheduling Preferences

SECTION 5 — Session Logistics

SECTION 6 — Technology & Access

SECTION 7 — Additional Notes

SECTION 8 — Consent & Policies