1:1 Private Coaching Experience with Dr. Colleen Carroll
Please fill out all questions fully in order to be considered. If you are a good fit, you will receive an email with directions to make arrangements for a personal consultation via phone or Zoom with Dr. Carroll. Due to the urgency of many clients, do not submit this form unless you are ready to move forward with creating a success plan for your family.
Email address *
Parent's full name: *
Your answer
Email address: *
Your answer
Phone number with area code and country code if outside USA: *
Your answer
What are you seeking help with regarding screen addiction and your child? Please be specific. Include age and gender of child, as well as screen usage details. *
Your answer
Describe any other solutions you have tried to resolve this issue. *
Your answer
Please note, 1:1 coaching is a high-touch service with an excellent success rate when the parent(s) is consistent. As such, this is a much higher investment than a book, course or online program. How committed are you in investing at this level of service? *
Not committed at all at this time
Highly committed
Thank you for your interest in working closely with Dr. Carroll. Someone on our team will be in touch shortly with next steps. Please note, due to the high number of applicants, once you receive your email confirmation, you must schedule your consultation within 7 days or your application will be voided.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Innovative Reading. Report Abuse - Terms of Service