Empowerment Form for Parents Paretns Name * First Name Last Name Email * Phone (###) ### #### Child's Name * First Name Last Name Child's Age * Birthdate * Empowerment Form for Kids 1. What is motivating you to seek coaching for your child? (i.e. Do you have any concerns about your child? Are there struggles / challenges your child is dealing with?) * 2. What impact is this having on your child? * 3. What impact is this having on you and your family? * 4. If you have attempted to address this issue in the past, what was tried and what were the results? * 5. What are 3-5 outcomes you would like to see as a result of me working with your child? * 6. When these outcomes are achieved, how do you envision it will impact your child? * 7. When these outcomes are achieved, how do you envision it will impact your family? * 8. What is your childs favorite color? * 9. What is your favorite thing to do as a family ? Why do you all enjoy it? * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you! I will be in touch shortly.
