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Yes! I'd Like to Schedule a "Take the Stress Out of School" Strategy Session with Pat
Thank you for requesting a complimentary "Take the Stress Out of School" Strategy Session. It's my pleasure to set aside a small amount of time each month to meet with families who are considering Academic Life Coaching as a next step.

Because my time is limited and coaching is only successful if the student is a willing participant, I request that the student fills out an application. However, the parent may ALSO fill out this survey, so that I have access to both party's perspectives.

All information is completely private and confidential. I'll be in touch soon to let you know about next steps!

Who is filling out this form?
What is your city, state, and time zone?
Your answer
How did you find out about me?
Your answer
How does the student feel about the idea of receiving coaching?
Your Contact Info, Please:
Student's First and Last Name
Your answer
Student's Grade Level
Your answer
Student's Email Address
Your answer
Student's Cell Phone Number
Your answer
Parents' Names
List the name of any parents who might be communicating with me.
Your answer
Parents' Phone Numbers
List the preferred phone number first and then any alternative numbers.
Your answer
Parents' Email Addresses
List the preferred email addresses
Your answer
Students, Now Tell Me More About You...
What are your strengths, special skills, hobbies, and interests?
In other words, what activities make you feel happy and energized? Please be specific and as thorough as possible. Part of de-stressifying school is having more of the good in your life, so I want to know what that is.
Your answer
What is your single biggest struggle or challenge at school with which you would like help?
Please be as thorough and specific as possible. The more I know, the more I can figure out the best methods of helping you.
Your answer
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 bullying? Or struggles with depression? Or moving between two households? You may not be comfortable sharing details, and that's ok, but it's helpful for me to know if there are external stressors that are contributing to your academic difficulties.
Your answer
What specific issues would you like addressed by academic life coaching?
Check all that apply.
Please describe the grades you are currently earning.
To what extent are these grades causing stress for you?
Your answer
Why are you serious NOW about taking action to improve your experience with school?
Your answer
Have you 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 of the testing. If you would rather have your parents complete this question, that's fine too.
Your answer
Finally...What Is Your Commitment Level to Your Academic Success?
Please answer these questions from the perspective of the person filling out the form. If you are the STUDENT, what is your commitment level in each of the following areas? If you are the PARENT, what is yours?
How much ENERGY are you willing to put towards your success at school?
Very low
Very high
How much TIME are you willing to put towards your success at school?
Very low
Very high
What else would you like me to know about your situation and/or commitment level before we schedule a meeting?
Your answer
You're finished! Sign up for your complimentary "Take the Stress out of School" Strategy session here: http://patladouceurmft.fullslate.com/
Your answer
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