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1:1 Coaching Application
12
Questions
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1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Age(s) of your child(ren.)
ex: 2, 4.5, etc.
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5
Select any other professionals you're currently working with?
Occupational Therapy
Physical Therapist
Speech Language Pathologist
Paediatrician
Early interventionist
Other
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6
What are the top 3 behaviours that you're currently struggling with? Be specific.
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7
What have you already tried to solve these challenges that hasn't worked?
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8
What have you already tried to solve these challenges that has (or has kind of) worked?
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9
What is your primary reason for seeking out 1:1 coaching vs. the group program?
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10
Are you committed to taking weekly action and executing our plans?
YES
NO
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11
List 5 things that you feel like you're "putting up with" right now.
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12
On a scale of 1-5 how happy are you with your child's behaviour right now?
1
2
3
4
5
Not at all
Very happy
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