• Teen / Family Coaching Application

    This form is to be filled out by a parent or guardian
  • I am a...
  • Gender

  • Please respond to the following statements honestly, based on how true they are for you right now. Choose one option for each statement:

  • I'm willing to consider a radically different perspective on my challenges, and make radical changes in my family, including lifestyle choices, parenting style, and communication and emotional skills.
  • As a parent or guardian, I'm willing to consider the role I may have played in things getting to where they are now.
  • I'm ready to fully claim my leadership role and authority as a parent.
  • I'm fully ready to claim my power as the primary adult in my child's life by making choices that they will be unhappy about, dislike me for, and challenge me on.
  • I believe it's not too late to salvage my relationship with my child, or their future.

  • AGREEMENT/REMINDERS:

    I understand that all information I entered in this form will be considered strictly confidential.

    The data gathered from this form will only be used as a basis for the type of coaching the client will need, and to assess fit.

    I understand that in order to be successful, it is vital to follow the plan agreed on by the coach and the client.

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