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

  • Format: (000) 000-0000.
  • Preferred Method of Contact*

  • SECTION 2 — Student Information

  • Does your child have an IEP or 504 Plan? (Optional)

  • SECTION 3 — Service Interest

  • What type of support are you interested in?*
  • Are you looking for short‑term or long‑term support?*
  • Are you interested in 1:1, small group, or both?*

  • SECTION 4 — Scheduling Preferences

  • Preferred Session Format*
  • Preferred Days*
  • Preferred Time Windows*
  • When would you like to start?*
  • Do you need a consistent weekly time or flexible scheduling?*

  • SECTION 5 — Session Logistics

  • Preferred Session Length*
  • How many sessions per week are you considering?*
  • Billing Preference*

  • SECTION 6 — Technology & Access

  • What device will your child use for sessions?*
  • Do you have reliable internet access?*
  • Does your child need support navigating online platforms?*

  • SECTION 7 — Additional Notes

  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • SECTION 8 — Consent & Policies

  • Please confirm the following:*
  • Should be Empty: