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Nameyour full name
Choose One
Age of Teen
Phone Number
Parentif applicable
Method of CoachingClick All That Apply

Please respond to the Following Statements on a scale of 1-5 with #5 being the strongest agreement with the statement.

I’m excited about developing life changing skills to help me.
I am extremely frustrated and impulsive with my emotions.
I feel so stupid around my peers.
I am willing to share and “speak straight” to my coach.
I am often overwhelmed in trying new things that are difficult.
I want to learn more about my brain and how it’s wired.
I am willing to put in energy on my end to make changes.
I struggle socially with my family and friends.
I am committed to making changes with my coach.

SCORE:

40-50 = EXCELLENT candidate to begin coaching

30-39 = VERY GOOD potential success in working with a coach

20-29 = Time may not be right for a coaching relationship

Less than 20 = Recommend alternatives other than coaching

CHECK ALL OF THE AREAS YOU WANT/NEED SUPPORT WITH

Check all that apply
Please provide comments on your current situation and where you would like to be in 3-6 months. Anything additional you would like to share?more details
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