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.

If you are completing this form for coaching for your child, please answer questions on behalf of your child; if you are completing it for parent coaching, please answer on behalf of both you and your child.

*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 your child (or you) are experiencing? *

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

Does your child (or you) have any other mental health diagnoses or learning disorders? *

Does your child (or you) currently taking any medication for ADHD or any other mental health diagnoses? *

Is your child (or are you) currently in therapy or has your child (or have you) previously received therapy? *

If you have a teenager, or a college-aged/ young adult child, we would encourage you to discuss coaching with them to see if they are open to it; if they are not wanting coaching, it will not be effective. In that case, 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 $800 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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