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Learning Coach

Occupational Therapy and Family Coaching for Lifelong and Neurodiverse Learners

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Group Info

If filling this out for another person, all fields should be about the person, and in their own words as much as possible.

Personal Info

Participant Name

Date of birth

City/town of residence

Contact Info

Contact Name

Phone Number

Group Info

Which groups are you interested in?

Creative Writers Weekly Workshop

Theater Improvisers

Rock Band Academy

Board Game Groupies

Goal-Getters 6-Week Course

Other (Describe in notes)

What goals would you like to achieve over the next 3 months?

What are the biggest barriers in the way of meeting those goals right now?

Setting Info

What times of day most match your availability?

Early Morning

Late Morning

Early Afternoon

Late Afternoon

Early Evening

Mid-Evening

How many of your peers (from 0 to 4) do you think would be interested in joining this group with you?

Additional Information

What other questions or notes do you have for Learning Coach?

Talk with Learning Coach about your current life situation, your ideal life situation, the obstacles between them, and the path ahead.

First Name

Last Name

Phone (Optional)

Your message

Thanks for submitting!

Learning Coach, LLC - Bellingham, WA - (360) 207-4560 - chris@learningcoachwa.com

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