EmpowerU: Parent Intake

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We are thrilled that your student has agreed to begin to make positive change in their well-being with EmpowerU. We have a few questions to help us personalize the course for your student.

Email *

What is the student's first and last name? *

What is your relationship to the student? *

Parent

Legal Guardian

Other:

Required

What school does your student currently attend? *

What is your student's cell phone number? (We will use this to communicate reminders for lesson completion) *

What is the student's gender? *

Female

Male

Non-Binary

Prefer not to say

Other:

What grade will your student be in school in 2020/21 *

What is your student's school counselor email address? *

What is your student's race? *

Prefer not to specify

African

African American/Black

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Caucasian/White

Other

Required

How would your student identify their ethnicity as: *

Not of Hispanic Origin

Mexican

Other Specific Hispanic

Peurto Rican

Other

Prefer not to specify

Unknown

Required

I have discussed the requirements of the course with my student. They understand that the course requires an average of 5 lessons a week - each one is 20-30 minutes to complete -- and at the pace the course is completed in 12 weeks. (Final date is 8/28/20 for course) Upon completion, the school and the parent/caregiver will get a report. The parent/caregiver and student will also receive updates for non-engagement. *

YES

What have you tried at home to help your student? Note whether it has been helpful or not helpful.

Check all of your student's current stressors. *

School or academics

Social pressures

Changes in his/her body

Body image

Negative thoughts or feelings about self

Unsafe living environment or neighborhood

Problems with friends and/or peers at school

Separation or divorce of parents

Chronic illness or disability

Moving or changing schools

Taking on too many activities or having too high of expectations

Financial

Busy schedule

Future planning (e.g. going to college, career choices, etc.)

Other:

Required

Which of the following are you concerned about for your student? *

Anixety/Stress level

Low mood/despression

Motivation/perserverence

Digital footprint and choices with phone

Amount of technology usage

Attention/Focus

Alcohol use

Tobacco use

Recreational Drugs including marijanna

Anger/definance

Required

Is there a current official mental health or learning diagnosis that would be helpful for us to be aware of? *

I agree to allow EmpowerU to discuss my child's progress with his/her school counselor or designated EmpowerU school contact as needed, including grades, attendance, school progress/health. Any released information will be held confidential between parties and used solely for the purposes of student goal setting and success in the EmpowerU course. Type "I agree" below as official release. (for more on EmpowerU privacy policy, check our website at empoweru.education) *

Thank you so much for completing this form. Be sure to click submit! You will receive an automatic email with a link to pay the $450 course fee. You can pay with Health Saving Account Credit Card.

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