Pre-Workshop Questionnaire for Teens

Name:
Email:
Cell #:
School:
Age:
Grade:
Parent's Name
Parent's Email:
Parent's Cell#
Parent's Occupation:
How did you hear about us?
Rate the following as it applies to you:
10 highest (This is NOT a problem in my life. I'm doing really well with this.)
5 mid (This is SOMEWHAT of a problem in my life.)
1 lowest (This is a BIG problem in my life. I’m not doing well with this.)
Motivation
Happy at School
Feeling Lonely
Healthy Body Weight
Happy at Home
Self Esteem
Exercise 3x/week
Happy with Friends
Conflicts with others
Body Pain
Meditating Daily
Depression/Sadness
Stress/Anxiety
Getting a job
Communication Issues
Tired/Fatigued
Grades
Achieving Goals
Fearful
Organizational skills
Making good Decisions
Mental Focus
Supporting others
Paying for College
Confidence
Time Management
Keeping Commitments
Job Skills
Lacking in Purpose
Planning my Future
Job Interview Confidence
Writing a Resume
Researching Career Options
How long have you had these challenging issues?
When the issue is at its worst, how does it feel?
Does this cause:
MoodinessSleep InterruptionsRestrictions on Daily Activities/Hobbies
Does this affect your:
AttitudeProductivityStaminaPatienceFamily
Have you ever had a life coach?
YesNo,
or a therapist?YesNo   
If so, when?
How many sessions?
If we could find the cause of the problems would you want to get rid of them?YesNo