Mental Performance Coaching for High School Student-Athletes

I understand and acknowledge that all information on this form and future calls/communication with Coach M are confidential.

Who is participating in completing this form? Please select all that apply. (It is encouraged for the student athlete and an additional trusted adult to fill out this application together).

Student-Athlete's Details:

Please have your student-athlete fill out this portion of the application. There is a separate section later for parents and other trusted adults.

Legal Name

First NameLast Name

Preferred Name (if any)

Age

Grade Level

Current High School

Student's Cell Phone Number

Format: (000) 000-0000.

Student's Personal E-mail (not affiliated with an academic institution)

example@example.com

Primary Sport

Primary Position

Secondary Sport and/or Secondary Position

Other Sport(s) of Notable Skill/Training?

Height

Weight

Please check all statements that apply.

What specific goals do you have for yourself?

Please check all statements that apply to your current state.

What are the main issues/setbacks that you currently face?

List 3-5 words that best describe yourself.

How would you best describe your attitude towards your current athletic coaches?

How would you best describe your attitude towards your current academic performance and/or your current high school experience overall?

What kind of athletic training have you experienced personally? Give as much detail as possible (Summer athletic programs, personal training, private coaching, etc.)

Please give a summary of your current academic standing. Are you proud of your grades? Do you take advanced or high-level classes? Do you feel challenged in school? Do you want to pursue higher education at a college or university?

Are you currently on any prescribed medication?

Are you currently taking any vitamins or other supplements?

Are you currently involved with marijuana, vaping, smoking, or any illegal drugs?

How can Coach M help you with your mental performance as a student-athlete?

How eager are you to work with Coach M?

What are your best available times to meet with Coach M? (Your availability should not interfere with schooling, practice time, games, or prior commitments such as jobs or other responsibilities).

What are your preferred method(s) of communication with Coach M? (Select all that apply).

Managing Parent's Details

Main parent managing your student-athlete, will also serve as Coach M's primary household contact.

Full Name

First NameLast Name

Cell Phone Number

Personal E-mail

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supportive Parent or other Trust Adult:

Managing parent's spouse/partner or other trust adult in your student-athlete's life.

Full Name

First NameLast Name

Cell Phone Number

Personal E-mail

Current Address (if different than managing parent's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Both Parents or other Trust Adults:

Please fill out this section with any adults listed on this form.

Please describe the current household structure and dynamics of your student-athlete's primary residence.

What are your sensory areas of concern?

To your knowledge, is your student-athlete currently involved with marijuana, vaping, smoking, or any illegal drugs?

Coach M prefers text updates on performance and attitude along with periodic meetings to discuss your student-athlete's progress. How involved would you like to be in regards to communication with Coach M?

I understand and acknowledge Coach M's service rates are $150/hour or $80/30 minutes. This includes Student-Athlete Coaching and Parent Counseling. Pricing for a pre-paid 5 session package is $750/five one-hour sessions or $400/five 30-minute sessions.

To help my student-athlete succeed, I'm interested in: (select all that apply)

I give Coach M permission to give my student-athlete extended time on sessions as necessary to help with breakthrough and performance results. Additional time will be pro-rated.

Preferred Payment Method: (select all that apply)

I understand and acknowledge that Coach M does not accept insurance.

Coach M is available to parents and I understand that every phone call with Coach M is billable time & pro-rated. Urgent individual texts to Coach M may be sent with no charge.

As a new client of Coach M, your student will receive the included items below for a one-time new client fee of $100:

Application review by Coach M
Session-by-session meeting progress record
Virtual parent in-take meeting with Coach M
Virtual student-athlete meeting with Coach M

I understand Coach M's one-time new client fee of $500 and everything it includes.

I understand that pre-payment is required for new-clients once my student-athlete's first appointment is confirmed.

Coach M's scheduling is done via text message on Sundays. I understand that Coach M stays booked and that I will be charged unless 24 hours notice is given to reschedule an appointment with Coach M.

I understand that Coach M cannot be held liable for any future actions by my child that may result in injury, damages, financial, and otherwise.

Please share any additional info Coach M may need to know.

How did you hear about Coach M's Mental Performance Coaching? If referral, please provide name.

Thank you for your time and commitment. I look forward to working with your athlete so they can maximize their performance and be the best they can be. Please text Coach M at (612) 987-3191 that you have submitted an inquiry form to expedite your first meeting!

Sincerely,

Roger Maupin