Canada-Registration - Maxi Mind Learning

Student Name*

First Last

Primary Email*

This email address should match the primary email on all your Maxi Mind forms

Date of Birth

Home Phone

Address

Street Address Address Line 2 City Province Postal Code

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Mother’s Name

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Cell

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Father’s Name

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Cell

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Parent

Relation*

Name*

Cell*

Email*

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Scheduling Notes

Preferred Days/Times

NOT These Days/Times

Preferred # of Sessions /week

Allergies?

Epipen

Yes

Do you have Extended Health Insurance?

Yes

Other Important Notes

Course Options – Select one*

Skill SharpenerSuitable for well-functioning students seeking further improvement, by boosting their focusing and cognitive skills.24 Sessions - $3600

Focus Master Ideal for struggling students seeking substantial improvements in focusing, learning and self-regulation skills. 40 Sessions - $6000

Brain Balancer Targets the needs of students who are more substantially delayed in focusing, learning and self-regulation skills. 60 Sessions - $9000

✔ Each course is individually customized according to the child’s specific profile and needs.

✔ Sessions are administered by a Maxi Mind certified Neuroeducational Therapist.

✔ Maxi Mind services are overseen by a registered psychologist and are therefore HST exempt.

Disclaimer, terms and conditions: Maxi Mind does not provide any medical diagnosis or treatment for any medical condition. Its programs are proven to boost mental performance but results may vary. Client agrees to pre-pay scheduled appointments at least one month in advance. Appointment cancellations must be called in at least 24 hours in advance, barring unforeseen emergencies. Client agrees that Maxi Mind may utilize non-identifying data for statistical or marketing purposes. Registration is processed with an initial payment of $1400, with a non-refundable portion of $700.

Signature

$1500 CAD

Price:

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Maxi Mind Registration Form

Scheduling Notes

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