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