Raising Kings Discovery Form

Raising Kings Discovery Form

Let's get ready to put in work
Customer Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
How old is your son?*
if more than one, separate ages with comma.
Are you currently raising any other children? if so, what are their ages?
f more than one, separate ages with comma.
Communication & Relationship
How would you describe your communication with your son?*
ex: excellent, ok, needs work, bad
What are the biggest communication challenges you face with your son?*
ex: resistance, misunderstandings or emotional shut downs
Do you feel your son listens and respects your guidance? If not, what seems to be the barrier?*
ex: lack of respect, shutting down
Emotional Well Being and Mental Health
Has your son shown any signs of stress, anxiety, or emotional distress? If so, how is he coping with these emotions*
How do you typically manage your son's emotions when he's upset, angry or withdrawn?*
Do you have any strategies yet to help your son feel heard, understood and supported emotionally?*
No is a totally acceptable answer, that's why you're here.
Academics and Behavior
How is your son performing academically? Are there specific challenges he's facing at school?*
ex: grades, motivation, focus
How would you describe your son's attitude toward school and learning?*
Have there been any behavioral issues at school or home? If yes, please describe.*
Parenting Challenges
What's your biggest challenge as a single mom raising your son?*
be as specific as possible
Have you found a way to balance your responsibilities at home, work and with your son yet?*
What are your top three parenting goals right now?*
Do you have a support system, or do you feel isolated on your journey?*
Looking Ahead
What kind of changes or improvements are you hoping to see in your relationship with your son after our coaching sessions?*
What do you believe your son needs most in order to thrive?*
Why do you think now is the right time for you to seek guidance or coaching in raising your son?*
E-mail*
example@example.com
Once we have reviewed your answers, we'll schedule a consultation to dive deeper into your challenges and start creating a personalized plan to support you and your son. Let's get to work Queen.
How did you hear about us?*
Please Specify*
Suggestions if any for further improvement:
Will you be willing to recommend us?

YesNoMaybe

Please give reference of any two people whom you feel could benefit from this program and our free resources:

	Full Name	Address	Contact Number
1
2

Raising Kings Discovery Form

Communication & Relationship

Emotional Well Being and Mental Health

Academics and Behavior

Parenting Challenges

Looking Ahead