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Cogmed Training Interest Form

Thank you for your interest in Cogmed Working Memory Training. Please complete this brief form, and we will contact you to discuss whether the program may be appropriate for your child. Completing this form does not establish a provider–client relationship or guarantee enrollment.

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Please fill the following ^*

First Name ^*

Last Name ^*

Email ^*

Phone Number ^*

Child's Name

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Child’s age and current grade

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What concerns would you like Cogmed to help address? ^*

Check all that apply:

Attention or distractibility

Working memory

Following multi-step directions

Completing schoolwork

Organization

Other learning difficulties

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Has your child received any relevant evaluation or diagnosis? ^*

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No formal diagnosis

ADHD

Autism Spectrum Disorder (ASD)

Anxiety-related Disorder

Learning disability/dyslexia

Prefer to discuss during consultation

Other

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What type of Cogmed support are you interested in? ^*

Standard program with regular coaching and monitoring

Reduced-support program for families who can work more independently

Not sure—I would like a recommendation

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Can your child generally participate in computer-based training approximately 3–5 times per week with adult support as needed? ^*

Yes

Not Sure

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What days or times are usually best for a brief consultation? ^*

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Please sign here ^*

I understand that this is an interest form and not an emergency or clinical service. I consent to being contacted about Cogmed services.

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