Academics & College Prep Intake Form

Academics & College Prep Intake Form

Please fill out this form prior to your first session.
Student Name *

First Name Middle Name Last Name
Student Email *
example@example.com
Student Phone Number *
Please enter a valid phone number.
School *
Grade *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent Name *

First Name Last Name
Parent Email *
example@example.com
Parent Phone Number *
Please enter a valid phone number.
What is your reason for seeking mentoring and coaching for academics and/or college readiness? *
Educational Goals

Coaching & Mentoring Service Acknowledgement
1. I understand that all information entered in this form is accurate to the best of my knowledge and I am aware that it is considered strictly confidential.
2. As a client, I understand and agree that I am fully responsible for my physical, mental, and emotional well-being during my sessions, inlcuding my choices and decisions. I am aware that I can choose to discontinue services at any time.
3. I understand that coaching and mentoring is a professional client relationship that I have with Dr. Delorean that is designed to facilitate the creation/development of personal and/or professional goals. As well as help with identifying any programs so I can address the problems, and receive advice to meet the end goal for resolving those problems.
4. I undertand that coaching and mentoring is a comprehensive process that may involve all areas of life including work, finances, health, relationships, education, and/ or recreation. I acknowledge that deciding how to handle these issues, incorporating coaching into those areas, and implementing my choices is exclusively my responsibility.
5. I undertand that coaching or mentoring does not involve diagnosis or treatment of any mental disorders as defined by the American Psychiatric Association.
6. I undertand that Dr. Delorean services is not a substitution for seeking professional treatment from a licnsenced therapist and I undertand that referrals will be given to seek additional help if needed.
7. I understand that any desisions made are the responsiblity of the student and family. I acknowledge that Dr. Delorean will not be held responsible.
8. I understand that any advice given is only a recommendation and I do not have to proceed with it.
My signature below indicates my full understanding of this agreement.
Name *

First Name Last Name
Student Signature *

Clear
Date *

Month Day Year
Date
Parent Signature *

Clear
Date *

Month Day Year
Date

Informed Consent for Adolescent Services
Confidentiality

Coaches who work with adolescents have the difficult task of protecting the adolescent’s right to privacy while at the same time respecting the parent's or guardian's right to information. Mentoring and coaching is most effective when a trusting relationship exists between the coach and the adolescent/child. Privacy is especially important in securing and maintaining that trust. In our office,we provide individual sessions to adolescents and ensure the caregiver/parent is involved in the process through consultation with them. At times, the parent/caregiver may even participate in the sessions if needed. However, to ensure the child’s privacy we will not provide detailed information to the parent/caregiver regarding what the child shared unless the child provides consent. Instead, general themes, ideas and recommendations will be provided as well as support and encouragement to the parent/caregiver. If it is necessary to refer your child to a mental health professional, we will share that information with you. Other areas of confidentiality will be discussed during the first session with the adolescent in the presence of their parent/caregiver to ensure complete understanding and agreement prior to the initiation of workign with Dr. Delorean.
My signature below indicates my full understanding of this agreement.
Name *

First Name Last Name
Student Signature *

Clear
Date *

Month Day Year
Date
Parent Signature *

Clear
Date *

Month Day Year
Date

Payment & Policy
1. I am aware that Dr. Delorean does not accept insurance and I am responbisle for paying all fees upon booking of each session online.
2. I understand that at the time of booking I will be charged the full amount of my session.
3. I understand that I am to cancel or reschedule any sessions within 24 hours of my appointment.
4. I understand that there are no refunds for no-shows or failing to reschedule 24 hours before my appointment. *Fees are non-transferable.
My signature below indicates my full understanding of this agreement.
Name *

First Name Last Name
Student Signature *

Clear
Date *

Month Day Year
Date
Parent Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Academics & College Prep Intake Form

Coaching & Mentoring Service Acknowledgement

My signature below indicates my full understanding of this agreement.

Informed Consent for Adolescent Services

My signature below indicates my full understanding of this agreement.

My signature below indicates my full understanding of this agreement.