Parent Intake Form
Please fill out the questionnaire below in order to reserve your call.

The form will come to Jessica and one of two things will happen.

One, she’ll decide you're not a good match and she’ll let you know politely.

Or two, she'll decide you MIGHT be a good match and someone from our team will set up your call with Jessica.

Nobody will pressure you or hassle you. If you want to book a call, great. If not, no problem. We’re cool either way.

Jessica is only looking for high-caliber parents to help them transform their teen's confidence and mindset.

Forms will be reviewed on a first come, first-serve basis and we will contact you to set up a time to connect. 
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Email *
Today's Date *
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How did you hear about us? 
Who did you hear about us from so I can send them a thank you gift  <3 
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Which city & time zone are you in? *
Parent's Name *
Parent's Phone Number *
Address (for client gifts)
Child's Name *
Child's Birthday *
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Child's Email  *
Child's Phone Number  *
Child's City/State born in AND time of birth (This is for me to look up their Human Design-a personality test)
What is motivating you to seek mindset mentoring/life coaching for your child? (i.e. Do you have concerns about your child? Are there issues/challenges your child is dealing with?) *
What impact is this having on your child? *
What impact is this having on you?  What impact is it having on your family? *
If you have attempted to address this issue in the past, what was tried and what were the results? *
What are one to three outcomes you would like to see as a result of me working with your child?  Explain and elaborate on what these outcomes mean to you. Prioritize outcomes in order of importance. *
When these outcomes are achieved, how do you envision it will impact your child? *
When these outcomes are achieved, how do you envision it will impact your family? *
What are some of your child's hobbies/ things they enjoy doing? *
Is there anything else I should know about working with your child? *
What program(s) interested in? *
Required
How much are you willing to invest in your son or daughter to get to the next level? *
Please enter your Facebook Profile URL so we can connect :) *
Any additional notes you'd like to add :)  *
A copy of your responses will be emailed to the address you provided.
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