Registration JM





Child’s Information

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Parent Information









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Questionaire
Screening

In order to help determine if Working Memory Training is appropriate for your child, we are going to ask you two sets of questions.  The purpose of the first set of questions is to identify any condition or conditions that will prevent your child from participating in the training program.  The second set of questions provides a guideline to determine if training may be appropriate.  We will ask you to verify, sign and date your responses.  

 

Does your child have / has had a history of any of the following.





















You answered yes to one or more of the above questions and your child does not qualify for Cogmed Working Memory Training.  We encourage you to pursue other options for assistance before attempting Cogmed Working Memory Training. 

If you have answered “no” to the above questions, please continue with the registration process by answering the questions below.

Additional Questions

Children’s concentration difficulties are seldom manifested in exactly the same way. It is therefore likely that you won’t get a YES to all of the statements. However, if the answer is YES on several statements, the child could probably benefit from working memory training.  

 













Confidentiality Statement:  A Working Mind will not disclose the identity of any participant other than as required to conduct the Program.  Data (without participant identifiable information) will be used for research purposes as part of the Cogmed ongoing statistical measurement of results.  Statistics and results may be used so long as no participant identifiable information is used.

(Optional) Pediatrician Information


Pediatrician’s Address






Thank you for completing the registration form.  Please click on the “Register” button to submit the form.  You will be taken back to the Registration Page for payment options.


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