Academic Coaching Intake Form
Thank you for requesting a complimentary "Achieve Your Best in School with Less Stress" 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.

All information is completely private and confidential. I'll be in touch soon to let you know about next steps!
Who is completing this form? *
How did you find out about academic coaching? *
Your answer
Parent Information
Parent Email *
Your answer
Parents First and Last Names *
Your answer
Parent Phone Number *
Your answer
Student Information
Student's Email
Your answer
Student's Cell
Your answer
Student First and Last Name *
Your answer
What is your city, state, and time zone? *
Your answer
Age of Student *
Your answer
Student's School Name
Your answer
Current Grade Level *
Your answer
Has the student been tested for learning differences?
Your answer
What are the student's strengths, special skills, hobbies, and interests?
Your answer
Student's Current Grades *
Does the student use an organizer, planner, or calendar ?
When does the student study for tests?
What is the students' single biggest struggles or challenges at school with which you would like help? (check all that apply) *
Required
Why are you serious NOW about taking action to improve your experience with school? *
Your answer
How high is student anxiety about the situation at school?
very low
very high
How high is parental anxiety about the situation at school?
very low
very high
How much TIME is the student willing to put into your success at school? *
No time
As much time as I need
How much TIME is the student willing to put into your success with coaching? *
No time
As much time as I need
How much TIME are the parents willing to put into helping the student create healthy routines and effective structure?
No time
As much time as I need
To be answered by the person responsible for paying for coaching:People often ask me how much they will need to invest into coaching. Realistically, unless you are considering a group program, you should be able to invest $400 - $2000/semester for one-to-one coaching with me. How willing and able are you to make that level of investment without causing undue financial hardship? *
Not possible
Very Doable
What else would you like me to know about your situation and/or commitment level before we schedule a meeting?
Your answer
Please sign-up for a 30-minute Parent https://my.timetrade.com/book/84ZTQ
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