Caregiver Coaching Intake Questionnaire & Client Service AgreementPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Family InformationHow many children are in the household? *0123456Please tell us what you are hoping to achieve from coachingChild 1Child 1 First NameChild 1 Age<1123456789101112131415161718+Child 1 GradeNot in schoolPre-KK123456789101112CollegeChild 1 Additional DataIEP504Formal DiagnosisAny Additional Information you would like to share for Child 1?Child 2Child 2 First NameChild 2 Age<1123456789101112131415161718+Child 2 GradeNot in schoolPre-KK123456789101112CollegeChild 2 Additional DataIEP504Formal DiagnosisAny Additional Information you would like to share for Child 2?Child 3Child 3 First NameChild 3 Age<1123456789101112131415161718+Child 3 GradeNot in schoolPre-KK123456789101112CollegeChild 3 Additional DataIEP504Formal DiagnosisAny Additional Information you would like to share for Child 3?Child 4Child 4 First NameChild 4 Age<1123456789101112131415161718+Child 4 GradeNot in schoolPre-KK123456789101112CollegeChild 4 Additional DataIEP504Formal DiagnosisAny Additional Information you would like to share for Child 4?Child 5Child 5 First NameChild 5 Age<1123456789101112131415161718+Child 5 GradeNot in schoolPre-KK123456789101112CollegeChild 5 Additional DataIEP504Formal DiagnosisAny Additional Information you would like to share for Child 5?Child 6Child 6 First NameChild 6 Age<1123456789101112131415161718+Child 6 GradeNot in schoolPre-KK123456789101112CollegeChild 6 Additional DataIEP504Formal DiagnosisAny Additional Information you would like to share for Child 6?What kind of coaching are you looking for? *Caregiver CoachingVirtual Learning CoachingParent 2 Parent SupportFrom Low to High, rate the amount of stress you feel about each of the following:Very LowBelow AverageAverageAbove AverageVery HighYour children's academic progressVery LowYour children's academic progress Very LowBelow AverageYour children's academic progress Below AverageAverageYour children's academic progress AverageAbove AverageYour children's academic progress Above AverageVery HighYour children's academic progress Very HighYour children's happiness/well-beingVery LowYour children's happiness/well-being Very LowBelow AverageYour children's happiness/well-being Below AverageAverageYour children's happiness/well-being AverageAbove AverageYour children's happiness/well-being Above AverageVery HighYour children's happiness/well-being Very HighYour family's ability to resolve conflictVery LowYour family's ability to resolve conflict Very LowBelow AverageYour family's ability to resolve conflict Below AverageAverageYour family's ability to resolve conflict AverageAbove AverageYour family's ability to resolve conflict Above AverageVery HighYour family's ability to resolve conflict Very HighThe impact of learning during COVID-19 on your familyVery LowThe impact of learning during COVID-19 on your family Very LowBelow AverageThe impact of learning during COVID-19 on your family Below AverageAverageThe impact of learning during COVID-19 on your family AverageAbove AverageThe impact of learning during COVID-19 on your family Above AverageVery HighThe impact of learning during COVID-19 on your family Very HighHow did you hear about us?Recommendation from someoneSocial MediaWebsiteSearch EngineOtherAdditional information you would like to shareSliding Pay ScaleYes, I am interested in the sliding pay scalePlease describe the reason you are requesting the sliding pay scaleWhat fee per session (in dollars) would be ideal for your family at this time? Selected Value: 50By signing this form you agree to all of the terms and conditions in our Client Service Agreement *Clear SignatureView the terms and conditions in our Client Service AgreementSubmit Share Share Tweet Pinterest Email