Kids Life Coaching Pre-Survey
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Email *
First and Last Name of Adult Completing Form *
First Name, Age, Gender, and Grade of Young Person
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Location: City or Town in the San Francisco Bay Area
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What is your primary reason for wanting your child to partner with Ashley as a Coach?
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In what areas do you see your child excelling?
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Required
What non-screen-related activities does your child enjoy and helps them deeply focus?
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In what areas would you like to see your child grow?
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Required
What are your child's top challenges with which you would like Ashley's support?  Select the top 2 areas although there can be other areas. 
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Required
From your perspective, what happens if your child does not get the help you are seeking from a kids' life coach? *
Does your child vape to cope with stress? *
Does your child smoke marijuana to cope with stress *
Does your child take pills to cope with anxiety? *
Has your child been a victim of sextortion or other forms of online mental abuse? *
Has your child been a victim of online or in-person bullying? *
Please describe the type, duration, and intensity of the bullying? If this does not apply to your child, write NA. *
Is your child currently receiving therapy and or psychiatric services? *
Describe any diagnoses your child has. Put NA if this not applicable to your child. *
Is your child a member of any online groups that highly influence the way they think, make decisions, and behave? *
Is your child a member of any clubs or gangs that highly influence the way they think, make decisions, and behave? *
How many hours do you estimate your child spends on social media and or YouTube per day? If your child is not on social media, reply NA. *
Required
Have you talked to your child about your desire for them to meet with a personal development coach? *
What are your child's thoughts on working with a personal development coach? If you have not spoken to them, reply NA. *
How much time do you intentionally spend helping your child create the success you want them to experience?
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What do you hope expect to achieve with Ashley's support that you cannot achieve on your own?
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Which program would you like to experience?
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Required
Do you have any additional questions after completing this form? *
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