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Learning Leaf: Parent Coach Consultation Form
In order to get started and best help you, we will need some information. Please fill out this form for either the Parent Coach or the Parent Math Coach
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First and Last Name
*
Your answer
Email
*
Your answer
Billing Address: House number, Street, City, State, Zip Code
*
Your answer
Phone Number
*
Your answer
Your child(ren)'s age and year in school
*
Your answer
School District Your Child(ren) Attends
*
Your answer
I have read and agree to the terms found at this link:
http://www.mylearningleaf.com/terms/
*
Yes
Required
What do you feel is going well in your life right now?
*
Your answer
What are some of your strengths?
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Your answer
What areas would you like some support?
Your answer
I am struggling with the following: (Select all that apply)
*
Finding Balance
Motivation
Attention
Organization
Time Management
Stress Management
Feeling Overwhelmed
Routine
Help working with my child on academics
I'm not sure I just need to talk to someone other than the people in my house
I have no idea how to do common core math
Other:
Required
Comments or additional information
Your answer
Thank you for taking the time to fill out this important form. We look forward to working with your family. If you have any questions please ask below or contact us at
info@mylearningleaf.com
.
Your answer
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