Contact Number *

Email *

Preferred Method For Communication *

Email

Text

Phone Call

Child First Name *

Child Last Name *

School Type *

Public

Charter

Private

Homeschool

Preferred Language for Coaching *

English

Spanish

Type of Session *

In-person

Virtual

Both

What Academic Goals Do You Have For Your Child? *

Known Triggers We Should Be Aware Of? *

Currently in Therapy or Counseling? *

Yes

No

Previously

Open To Clinical Referrals? *

Yes

No

Let's Discuss First

Interested In Home Visits? *

Yes

No

Maybe

Signing Up Additional Children? *

Yes

Not Now

Interested In Family Coaching? *

Yes

No

Not Sure

Should Coaches Attend Games/Practices, If Available? *

Yes

No

Occasionally

Who Is Paying For Services? *

Self

Sponsor

Not Sure

Are You Aware This Is Private Pay And Not Insurance-based? *

Yes

No

I'd like to discuss

Ready To Begin Services? *

ASAP

30-60 days

Just Exploring

#1 Outcome You Hope To See From I Coach Youth *

Level of Parent Involvement *

Weekly Check-ins

As-needed

Family Sessions

Hands-off