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Parent Consultation Form- Renee Sullins Coaching
Thank you for taking the time to answer the following questions prior to the beginning of our time together. All information will be kept strictly confidential. Please return 48 hours prior to our session to my email address at
reneesullins@reneesullinscoaching.com
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Email
*
Your email
HOW CAN I SUPPORT YOU? TELL ME MORE...
Name of parent filling out form
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Your answer
Are you looking for support for your son or daughter?
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son
daughter
grandson
granddaughter
What grade (or year in college) is your son or daughter currently in?
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Your answer
1. What is your MAIN concern regarding your son/daughter right now? (there may be multiple issues; you can discuss those in a later question)
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Your answer
2. What (all) have you done in the past to work on THIS particular issue/situation?
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Your answer
2b. What has worked? (if anything)
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Your answer
3. Does your son/daughter struggle with any of these below (please check ALL that apply).
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stress
general anxiety
poor sleep habits
poor eating habits
executive function
procrastination
social anxiety
poor academic performance
low self esteem
poor time management
poor transitions between tasks
poor body image
depression
lack of clarity about college plans
lack of focus
low energy
ADD/ADHD
other learning difference
drug or alcohol use
self-harm
anger issues
Other:
Required
4. Is he/she taking any supplements or medications? Please list what they take and what it is for.
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Your answer
5. What would you love to see to change in their lives 30 days from now?
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Your answer
6. How would you feel if you got this result?
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Your answer
7. What do you hope to get out of our time together today?
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Your answer
8. How important is it for them to start making those changes now?
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very
not very important
neutral
9. Please feel free to include any additional background information that would be helpful during our time together.
Your answer
10. How did you hear about Renee Sullins Coaching?
*
Your answer
Phone number if you plan to schedule a complimentary consultation (optional)
Your answer
A copy of your responses will be emailed to the address you provided.
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