* Required fields
Name *
E-mail Address *
Child's Name *
Child's Date of Birth *
Child's Age *
Sex * Female Male
List all household members, their age, and their relationship to the child. *
Guardian's Name, if other than parents
Unnamed
Parents Marital Status * Married Separated Divorced Living together, unmarried
Is this child your * biological child stepchild adopted child
This child lives with * Both Parents Mother Father Sibling Guardian Other
Custody Arrangements * N/A Mother Primary - Father Visitation Father Primary - Mother Visitation Shared Custody Other
Address: Street *
City *
State *
Zip Code *
Home Phone *
Mother's Cell Phone *
Father's Cell Phone Number *
Guardian's Cell Phone Number
Child's Cell Phone
Child's Height and Weight *
Name & Adress of Child's School if currently enrolled
If child is not currently attending school, please explain why.
If the child is a young adult, not in school, and not employed, please explain why.
If your child is employed, name employer, describe your child's position, and how many hours worked a week.
Please provide a brief summary of your concerns regarding this child. *
Mother's Name
What are your hopes and expectations for the coaching process? *
My child has seen the following professionals regarding these same concerns. *
Please list all diagnoses your child has been given, by whom, and date. (month & year) *
Please provide a time line of all medications tried for all mental health diagnoses. To the best of your ability, give dose (mg.) & frequency. If no medication was tried, enter N/A. *
Please select your preferred appointment time option. Please note, all times listed refer to EST. * Monday between 10:00 & 12:00 p.m. Monday between 3:00 & 6:00 p.m. Tuesday between 10:00 & 12:00 p.m. Wednesday between 10:00 & 12:00 p.m. Wednesday between 3:00 & 6:00 p.m. Thursday between 10:00 & 12:00 p.m.
Please select your second time choice for your appointment . Please note all times refer to EST. * Monday between 10:00 & 12:00 p.m. Monday between 3:00 & 6:00 p.m. Tuesday between 10:00 & 12:00 p.m. Wednesday between 10:00 & 12:00 p.m. Wednesday between 3:00 & 6:00 p.m. Thursday between 10:00 & 12:00 p.m.
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