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
