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College Coaching Client Info
Please respond to the questions below and Meg will be in touch about the Fall 2023 Monday Night College Coaching Group. Thanks!
Meg Leahy, MS, NCC, BCC
484-222-0272
leahylearning@gmail.com
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Email
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Your email
Student's Full Name:
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Your answer
Student's Current Address:
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Your answer
Student's Best Phone #:
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Your answer
Student's
Billing/Mailing Address:
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Your answer
Student's
Age:
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Your answer
Student's
Birthdate:
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MM
/
DD
/
YYYY
Student's
Gender:
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Female
Male
Non-binary/Non-conforming
Transgender
Prefer Not to Answer
Other:
Student's Ethnicity:
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American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiin or Other Pacific Islander
White
Prefer Not To Answer
Other:
Number of Siblings/Position in the Family:
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Your answer
How did you find out about Leahy Learning?
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Your answer
Name of High School/Graduation Date
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Your answer
Name of College or University/Expected Graduation Date
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Your answer
Current Undergraduate Major and Minor
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Your answer
Current College GPA
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Your answer
SAT and/or ACT score
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Your answer
Have you ever had educational testing for accommodations? If so, when were you tested and what accommodations were you granted?
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Your answer
Parent 1 Name and Address:
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Your answer
Parent 1's Occupation and Employer:
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Your answer
Where did Parent 1attend college and/or post graduate? Please include dates of graduation:
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Your answer
Parent 2 Name and Address:
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Your answer
Parent 2's Occupation and Employer:
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Your answer
Where did Parent 2 attend college and/or post graduate? Please include dates of graduation:
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Your answer
Tell me about your college experience so far. How far into the program are you?
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Your answer
How would you generally describe yourself?
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Your answer
How would you describe yourself as a student?
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Your answer
What would you say you are good at?
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Your answer
What do you struggle with?
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Your answer
What are the main issues that have prompted you to seek help at this time?
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Your answer
What are your goals?
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Your answer
Have you been diagnosed with ADHD?
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Yes
No
Maybe
Do you suspect you have ADHD or Executive Function issues?
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Yes
No
Maybe
On a scale of 1 (lowest) to 10 (highest), how would you rate the amount of stress in your life?
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not really anything stressful
1
2
3
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5
6
7
8
9
10
everywhere I turn there is something stressful
On a scale of 1 (lowest) to 10 (highest), how would you rate your current level of anxiety?
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never anxious
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2
3
4
5
6
7
8
9
10
always anxious 24/7
Do you have any medical diagnoses? If so, please share:
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Your answer
Are you currently taking any medications? If so, please list:
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Your answer
Do you suffer from any allergies? If so, please list:
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Your answer
Do you see any other specialists? Therapists, psychiatrist, psychologist, coach, tutor, etc. If so, please provide their information:
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Your answer
Is there any other important information I should know? Family history, behavioral changes, triggers, etc.
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Your answer
Have you (or your family) suffered any significant traumas that I should know about? e.g. loss, abuse, illness, a significant move, separation from partner/family, etc?
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Your answer
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