Confident Brains Enquiry Form

Welcome to Thanyapura Brain Gym and the Arrowsmith Program. If you are interested in learning if the Arrowsmith Program is suitable for your needs, please take a few minutes to complete the Enquiry Form below. This form allows us to start to understand how we can meet your needs or the needs of your child, friend, or family member. Your information will be kept secure and confidential. This form is also the first step should you wish to enrol in the Arrowsmith Program™. After the form is submitted we will contact you with more information on possible next steps. Time required to complete the form: approximately 10 minutes.

Your Name (Full Name) Your Name (Full Name) * First Last
How did you find us?

How did you find us? Social Media Web Search Friend or Relative Other Other
Email Address
What is your relationship to the individual that is interested in participating in the Arrowsmith Program™? *

What is your relationship to the individual that is interested in participating in the Arrowsmith Program™? Parent Family Member Self Other Other
Is the Arrowsmith Program™ suitable for your needs?

The Arrowsmith Program™ is for individuals who would like to strengthen brain function and permanently improve cognitive capacities. It uses specialised training exercises to enhance abilities and provide a cognitive edge. It is also used as a leading method to address the underlying causes of Specific Learning Difficulties including dyslexia, dyscalculia, dysgraphia, processing and attention difficulties, and non-verbal learning challenges.

The Arrowsmith Program™ works to improve: reading, writing, maths, logic, reasoning, comprehension, processing speed, attention, memory, and non-verbal learning. It also strengthens abilities related to communication, executive functioning, social skills, independence, and self-confidence.

The Arrowsmith Program™ is a world leading, scientifically proven method to improve learning abilities. It was developed in Canada more than 40 years ago. It is highly customised to individual needs. The changes from the Arrowsmith Program™ are permanent and often described as life changing.

Please note that the Arrowsmith Program™ is not suitable for individuals with severe intellectual delay or Downs Syndrome. It is also not suitable for individuals who have severe emotional or behavior disorders that would prevent them from participating in sustained cognitive training exercises. Severe Autism, brain injury and some types of brain illness may affect rate of progress or the ability to participate in the Arrowsmith Program.
The following questions are designed to determine if the Arrowsmith Program may be suitable to meet your needs.
Please complete the following information for the individual interested in participating in the Arrowsmith Program. Please answer the questions honestly and to the best of your knowledge.
Name Name * First Last
Age *
City *
Country *

Please rate ability in the following categories: *
	Poor	Fair	Good	Excellent	Not Applicable
Cooperation with others	Cooperation with othersPoor	Cooperation with othersFair	Cooperation with othersGood	Cooperation with othersExcellent	Cooperation with othersNot Applicable
Conflict resolution	Conflict resolutionPoor	Conflict resolutionFair	Conflict resolutionGood	Conflict resolutionExcellent	Conflict resolutionNot Applicable
Listening skills	Listening skillsPoor	Listening skillsFair	Listening skillsGood	Listening skillsExcellent	Listening skillsNot Applicable
Ability to focus	Ability to focusPoor	Ability to focusFair	Ability to focusGood	Ability to focusExcellent	Ability to focusNot Applicable
Using time productively	Using time productivelyPoor	Using time productivelyFair	Using time productivelyGood	Using time productivelyExcellent	Using time productivelyNot Applicable
Responsibility	ResponsibilityPoor	ResponsibilityFair	ResponsibilityGood	ResponsibilityExcellent	ResponsibilityNot Applicable
Honesty	HonestyPoor	HonestyFair	HonestyGood	HonestyExcellent	HonestyNot Applicable
Compassion	CompassionPoor	CompassionFair	CompassionGood	CompassionExcellent	CompassionNot Applicable

If school aged, is an aide/teaching assistant/education assistant/shadow required to stay on task?
If YES, please describe.
Please describe ability to work independently. *
Please describe any behavioural or other concerns that might interfere with the ability to participate in sustained training exercises. *
Please describe ability to comply with rules or instructions. *
Please describe ability to deal with frustration *
Please describe the desired benefits from participation in the Arrowsmith Program™ *

Please rate abilities in the following categories:
	Not at all	Sometimes	Often	All the time	Not applicable
Difficulty Sustaining attention in tasks or activities.	Difficulty Sustaining attention in tasks or activities.Not at all	Difficulty Sustaining attention in tasks or activities.Sometimes	Difficulty Sustaining attention in tasks or activities.Often	Difficulty Sustaining attention in tasks or activities.All the time	Difficulty Sustaining attention in tasks or activities.Not applicable
Listens when spoken to directly.	Listens when spoken to directly.Not at all	Listens when spoken to directly.Sometimes	Listens when spoken to directly.Often	Listens when spoken to directly.All the time	Listens when spoken to directly.Not applicable
Follows instructions.	Follows instructions.Not at all	Follows instructions.Sometimes	Follows instructions.Often	Follows instructions.All the time	Follows instructions.Not applicable
Avoids, dislikes or reluctantly engages in tasks requiring sustained mental effort.	Avoids, dislikes or reluctantly engages in tasks requiring sustained mental effort.Not at all	Avoids, dislikes or reluctantly engages in tasks requiring sustained mental effort.Sometimes	Avoids, dislikes or reluctantly engages in tasks requiring sustained mental effort.Often	Avoids, dislikes or reluctantly engages in tasks requiring sustained mental effort.All the time	Avoids, dislikes or reluctantly engages in tasks requiring sustained mental effort.Not applicable
Often distracted by external stimuli.	Often distracted by external stimuli.Not at all	Often distracted by external stimuli.Sometimes	Often distracted by external stimuli.Often	Often distracted by external stimuli.All the time	Often distracted by external stimuli.Not applicable
Often fidgets with hands or feet.	Often fidgets with hands or feet.Not at all	Often fidgets with hands or feet.Sometimes	Often fidgets with hands or feet.Often	Often fidgets with hands or feet.All the time	Often fidgets with hands or feet.Not applicable
Often 'on the go' or acts as if 'driven by a motor'.	Often 'on the go' or acts as if 'driven by a motor'.Not at all	Often 'on the go' or acts as if 'driven by a motor'.Sometimes	Often 'on the go' or acts as if 'driven by a motor'.Often	Often 'on the go' or acts as if 'driven by a motor'.All the time	Often 'on the go' or acts as if 'driven by a motor'.Not applicable
Often lose temper.	Often lose temper.Not at all	Often lose temper.Sometimes	Often lose temper.Often	Often lose temper.All the time	Often lose temper.Not applicable
Often argues with others.	Often argues with others.Not at all	Often argues with others.Sometimes	Often argues with others.Often	Often argues with others.All the time	Often argues with others.Not applicable
Often defies or refuse others' requests or rules.	Often defies or refuse others' requests or rules.Not at all	Often defies or refuse others' requests or rules.Sometimes	Often defies or refuse others' requests or rules.Often	Often defies or refuse others' requests or rules.All the time	Often defies or refuse others' requests or rules.Not applicable
Often deliberately does things that annoy other people.	Often deliberately does things that annoy other people.Not at all	Often deliberately does things that annoy other people.Sometimes	Often deliberately does things that annoy other people.Often	Often deliberately does things that annoy other people.All the time	Often deliberately does things that annoy other people.Not applicable

Are any of the following conditions known or suspected? Please check all that apply. *

Are any of the following conditions known or suspected? Please check all that apply. Brain Injury or Illness Severe or moderate Autism High functioning Autism or Asperger's Syndrome Downs Syndrome General Intellectual Disorder Pervasive Intellectual Disorder Physical challenges that prevent the ability to type or use a pen or pencil. None
Which course is right?

Full Time Program
The full time program is designed to improve a full range of cognitive abilities. It is the core of the Arrowsmith Program™, and is the standard option for complete brain training. This program type is 2 - 6 hours per day, 5 days per week. Our full time program starts mid August and continues through June the following calendar year. Ongoing enrolment is available if space allows. Available in-person and online.

6-Week Cognitive Intensive Program (CIP)
A rigorous program using the Specialised Symbol Relations cognitive exercise. It is designed to improve processing abilities across all academic disciplines, maths, logic, understanding of cause and effect, social abilities and general insight. 6 hours per day, 5 days per week, 6 weeks. Several available start dates throughout the year. Available in-person only.

8-Week Cognitive Intensive Program (CIP) Online
A rigorous program using the Specialised Symbol Relations cognitive exercise. Similar to the 6-Week CIP above, but offered in an 8 week format to accommodate online participation. 3-4 hours per day (depending on age), 5 days per week, 8 weeks. Several available start dates throughout the year. Available online only.

6-Week Brain Training Summer Camp
A rigorous program using the Specialised Symbol Relations cognitive exercise. Similar to 6-Week CIP above. Includes sport and activity at world class facilities. 6 hours per day, 5 days per week, 6 weeks. Anticipated start date for our next Brain Training Summer Camp is 28 June - 5 August, 2020. Available in-person only.

Cognitive Enhancement Program
A daily brain workout designed to provide a cognitive edge. The Cognitive Enhancement Program uses the specialised Symbol Relations cognitive exercise to improve processing abilities across all academic disciplines, maths and logic, understanding of cause and effect, social abilities and general insight. 4 hours per week with flexible scheduling. Available in person and online.
I am most interested in the following program: *

I am most interested in the following program: Full-time Program 6-Week Cognitive Intensive Program 8-Week Cognitive Intensive Program Online 6-Week Brain Training Summer Camp (Ages 9-18) Cognitive Enhancement Program (40 min per day for 10 months) I am unsure at this time.
Additional information you would like to add:

Confident Brains Enquiry Form

Confident Brains Enquiry Form

Is the Arrowsmith Program™ suitable for your needs?

The following questions are designed to determine if the Arrowsmith Program may be suitable to meet your needs.

Please complete the following information for the individual interested in participating in the Arrowsmith Program. Please answer the questions honestly and to the best of your knowledge.

Which course is right?