Student Intake Form

Student Intake Form - Study & Strategy Session

Program & Timeline

Full Name *

Email *

Phone *

Which program are you preparing for?

CNA Certification Prep

Medical Assistant Prep

Medical Administrative Specialist Prep

Medical Billing Prep

Timeline & Goals

Target exam or completion date *

How urgent is your timeline? *

Very urgent (need to pass within 1-2 months)

Somewhat urgent (need to pass within 3-4 months)

Flexible timeline (5+ months)

Study Commitment & Availability

How many hours per week can you realistically commit to studying? *

0–5 hours

6–10 hours

11–15 hours

16–20 hours

20+ hours

What days and times work best for your study schedule? *

What are your biggest time constraints? (select all that apply) *

Full-time work schedule

Family/childcare responsibilities

School commitments

Irregular work hours

Other major commitments

Experience & Background

Do you have any healthcare experience or training? *

No healthcare experience

Some healthcare experience (less than 1 year)

Moderate healthcare experience (1-3 years)

Extensive healthcare experience (3+ years)

Have you attempted this certification exam before? *

No, this is my first attempt

Yes, I've attempted this exam before

Yes, I've attempted a different healthcare certification

Learning Preferences & Challenges

What is your preferred way to learn new material? *

Visual (videos, charts, diagrams)

Reading/Writing (textbooks, notes)

Hands-on practice and application

Discussion and explanation

Combination of methods

What are your biggest study challenges? (select all that apply)

Time management and staying organized

Test anxiety and stress

Staying motivated and consistent

Understanding complex concepts

Retaining information long-term

Applying knowledge to test questions

Lack of clear study direction

Areas of Concern & Support Needs

Based on what you know about your chosen program, what topics or skills are you most worried about? *

How comfortable are you with technology and online learning tools? *

Very comfortable - love using apps and digital tools

Somewhat comfortable - can learn new tools with guidance

Basic comfort - prefer simple, straightforward tools

Need support - not very comfortable with technology

What type of support and accountability works best for you? *

I'm very self-directed, just need a good plan

I like regular check-ins and progress updates

I need structured deadlines and assignments

I work best with frequent guidance and support

Goals & Final Details

What is your main goal for earning this certification? What will success mean to you? *

How committed are you to following a structured study plan? *

Extremely committed - I'll stick to the plan exactly

Very committed - minor adjustments are okay

Moderately committed - I may need some flexibility

I'll try my best but may need extra support

Is there anything else important we should know about your situation, schedule, or learning needs?