Yes, I’d like to schedule a free strategy session Who is submitting this form? ParentStudentOtherWhat is your city and state? How did you find out about me? How does the student feel about the idea of receiving coaching? Relieved and ready for helpOpen but cautiousResistant and/or waryThe student doesn't know about it yetOtherYour contact information, please: Student's First and Last Name Student's Grade Level Student's Email Address Student's Cell Phone Number Parent's Names (List names of parents who might be communicating with me.) Parents' phone numbers (List preferred phone number first and then any alternate phone numbers) Parents' email address Student's permanent address Tell Me More About You In other words, what activities make you happy and energized? Please be specific and as thorough as possible. Part of reducing school-related stress is having more of the good in your life, so I want to know what that is. What is the student's single biggest struggle or challenge with which you would like help? Please be as thorough as possible. The more I know, the more I can figure out the best methods of helping you. What struggles or challenges in life contribute to stress at school? Sometimes stress in other areas of our life contribute to stress at school. Maybe it's an annoying sibling? Or struggles with depression? Or bullying? Or moving between two households? You may not be comfortable sharing these, and that's okay, but it's helpful for me to know if there are external stressors that are contributing to your academic difficulties. What specific issues would you like addressed through academic life coaching. Check all that apply.Time managementOrganizationStudy skillsWritingClear communication with parentsSelf-advocacy with teachersNotetakingTest anxietyPlanning and thinking aheadLack of motivationInitiating workProcrastinationTrying too hardSelf esteem as a studentCompulsive perfectionismotherPlease list the subjects and grades you are currently getting. To what extent are these causing stress for you? Why are you serious NOW about taking action to improve your experiences with school? Has the student been tested for learning differences? If so, please list the date of testing, the psychologist who did the test, and a few notes about the results. How much ENERGY are you willing to put towards your success at school? 1 is very low and 10 is very high. 12345678910How much TIME are you willing to put towards your success at school? 12345678910What else would you like me to know about your situation and/or commitment level before we schedule a meeting? Email VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
