Caregiver Coaching Intake Questionnaire & Client Service Agreement

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Family Information

How many children are in the household? *

Please tell us what you are hoping to achieve from coaching

Child 1

Child 1 First Name

Child 1 Age

Child 1 Grade

Child 1 Additional Data

IEP
504
Formal Diagnosis

Any Additional Information you would like to share for Child 1?

Child 2

Child 2 First Name

Child 2 Age

Child 2 Grade

Child 2 Additional Data

IEP
504
Formal Diagnosis

Any Additional Information you would like to share for Child 2?

Child 3

Child 3 First Name

Child 3 Age

Child 3 Grade

Child 3 Additional Data

IEP
504
Formal Diagnosis

Any Additional Information you would like to share for Child 3?

Child 4

Child 4 First Name

Child 4 Age

Child 4 Grade

Child 4 Additional Data

IEP
504
Formal Diagnosis

Any Additional Information you would like to share for Child 4?

Child 5

Child 5 First Name

Child 5 Age

Child 5 Grade

Child 5 Additional Data

IEP
504
Formal Diagnosis

Any Additional Information you would like to share for Child 5?

Child 6

Child 6 First Name

Child 6 Age

Child 6 Grade

Child 6 Additional Data

IEP
504
Formal Diagnosis

Any Additional Information you would like to share for Child 6?

What kind of coaching are you looking for? *

Caregiver Coaching
Virtual Learning Coaching
Parent 2 Parent Support

From Low to High, rate the amount of stress you feel about each of the following:

	Very Low	Below Average	Average	Above Average	Very High
Your children's academic progress	Very LowYour children's academic progress Very Low	Below AverageYour children's academic progress Below Average	AverageYour children's academic progress Average	Above AverageYour children's academic progress Above Average	Very HighYour children's academic progress Very High
Your children's happiness/well-being	Very LowYour children's happiness/well-being Very Low	Below AverageYour children's happiness/well-being Below Average	AverageYour children's happiness/well-being Average	Above AverageYour children's happiness/well-being Above Average	Very HighYour children's happiness/well-being Very High
Your family's ability to resolve conflict	Very LowYour family's ability to resolve conflict Very Low	Below AverageYour family's ability to resolve conflict Below Average	AverageYour family's ability to resolve conflict Average	Above AverageYour family's ability to resolve conflict Above Average	Very HighYour family's ability to resolve conflict Very High
The impact of learning during COVID-19 on your family	Very LowThe impact of learning during COVID-19 on your family Very Low	Below AverageThe impact of learning during COVID-19 on your family Below Average	AverageThe impact of learning during COVID-19 on your family Average	Above AverageThe impact of learning during COVID-19 on your family Above Average	Very HighThe impact of learning during COVID-19 on your family Very High

How did you hear about us?

Additional information you would like to share

Sliding Pay Scale

Yes, I am interested in the sliding pay scale

Please describe the reason you are requesting the sliding pay scale

What fee per session (in dollars) would be ideal for your family at this time?

Selected Value: 50

By signing this form you agree to all of the terms and conditions in our Client Service Agreement *

View the terms and conditions in our Client Service Agreement