Mental Conditioning Youth Services Intake Form

Our coaching offers you a fresh perspective on goals you haven’t been able to achieve in life YET! We seek to reorganize your priorities in life that will empower you rather than you continuing on an unsuccessful path. We are an accountability team, by your side, step by step to ensure you see things through.

Defining Our Accountability Guide; someone who’s there for you through life’s most difficult and challenging times. A guide to help you see things differently, refine your approach and understanding to assist you in achieving your goals. We provide unbiased feedback and evaluation only to achieve successful results.

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Please check the items that you believe is affecting you

Answer each question below with either a 0, 1, 2, 3, or 4

· 0 = Never

· 1 = Almost Never

· 2 = Sometimes

· 3 = Fairly Often

· 4 = Very Often

1. In the last month, how often do you wake up angry or sad?

2. In the last month, how often have you gone to bed angry or sad?

3. In the last month, how often have you felt that you were unable to control your anger?

4. In the last month, how often have you felt nervous about something?

5. In the last month, how often have you felt confident in yourself?

6. In the last month, how often have you been upset with your parents/gaurdians?

7. In the last month, how often have you been mad at friends or other authority (teachers)?

8. In the last month, how often do you think about being great?

9. In the last month, how often have you helped others?

10. In the last month, how often do have a smile on your face (laughter)?

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Date Completed

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Youth Services Intake Form

LIFE SCHEMATICS