PRE-SCREENING FORM FOR PARENTS/CAREGIVERS

We are here to help anchor you with 1:1 coaching services.

The first step is to complete this brief confidential pre-screening form. This helps us understand your needs and to be sure that coaching is the right fit for your situation; it should take about 5 minutes to complete.

*Required responses. Please write N/A if not applicable.

First Name of person completing form: *

Last Name of person completing form: *

Email *

Phone *

How did you hear about us? *

Indicate what type of coaching you’re interested in (you can choose more than one): *

If you have a family member (young child/teen/college student) you’re seeking coaching for, please complete your one child’s information below OR if you want parent coaching, please list all applicable children below.

First Name(s): *

Age(s): *

Grade(s): *

Name of school(s): *

What is your relationship to the above person(s): *

Briefly explain why you are reaching out for coaching (1-3 sentences). What are the specific struggles you (or your family member/child) are experiencing? *

Have you (or your family member/child) been diagnosed with ADHD? (A diagnosis is not necessary for coaching.) *

Do you (or your family member/child) have any other mental health diagnoses or learning disorders? *

Are you (or your family member/child) currently taking any medication for ADHD or any other mental health diagnoses? *

Are you (or your family member/child) currently in therapy or have you (or your family member/ child) previously received therapy? *

If you have a teenager, we would encourage you to discuss coaching with them to see if they are open to it; if they are not wanting coaching, we encourage parent coaching instead.

If you are seeking coaching for your student, how open is your child to the idea of coaching? *

Are you open to parent/family coaching? *

Are you wanting: *

Where are you located?

City *

State *

Country *

Click below if you would like to be added to our contact list for:

Study Skills Workshops

Parent Coaching Group

I understand that 1:1 coaching rates vary by coach and will range from $500 to $720 per month. I am also aware that coaching is not covered by insurance (although Life Anchored Coaching can provide documentation for reimbursement if your HSA/FSA covers ADHD/EF Coaching.) *

If I am inquiring about services for my child/ adult child, I understand that my child/adult child needs to be in agreement for coaching services. I understand that coaching is not effective if my child or adult child does not want to be coached. *

Is there anything else that would be helpful for us to know? *

After pressing submit, you will find in your inbox a short 5-minute introductory video and next steps, should you decide to move forward with a pre-screening call.

Watching the video is a prerequisite to our call. Please check your spam folder if you don't receive an email in the next 5 minutes or contact [email protected] and let us know.

Thank you!

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