Intake Application 1:1 Mentorship
Please answer the questions in as much detail as you can so that I can provide the best assistance possible.
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E-mail *
Parent Name *
Student Name *
How old is your child *
On a scale of 1-10 how are they at home?
Struggling
Extremely happy
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On a scale of 1-10 how are they at school?
Struggling
Extremely happy
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On a scale of 1-10 how do they feel about their future?
Struggling
Extremely happy
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What are some goals they have for their home life?
Goals for school/academics?
Goals for their social life?
Share anything about the goals you have for your child (can be about life beyond school maybe for their future if applicable or home life or social life - ANYTHING)
What do you think are the biggest roadblocks in accomplishing the goals listed above?
Explain the goals/struggles you would like to see worked through with our time together
Does your child struggle with any of the following *
Obrigatória
Does your child have any additional resources they use (i.e. therapist, psychiatrist, guidance counselor)?
Are there any concerns you currently have with you child?
Are there any hesitations or questions you have about joining our 1:1 mentorship?
Any other questions/concerns?
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