Teen Client Profile

Coaching Agreement

Please review the Family Coaching Agreement prior to completing this form. A copy of the agreement will be sent to you by email once you have paid for the coaching package, and an abbreviated version requiring your signature will be brought during our intake session. 

Teen's Information
Teen's Name *
Teen's Name
Teen's Birthdate *
Teen's Birthdate
Teen's Cell Number
Teen's Cell Number
Preferred Phone Number *
Preferred Phone Number
Please provide any social media services with your child's username.
Parents' Information
Home Address *
Home Address
Mother's Preferred Phone *
Mother's Preferred Phone
Father's Preferred Phone *
Father's Preferred Phone
Home/Secondary Phone
Home/Secondary Phone
Family Information
Secondary Parents
(if applicable)
Preferred Phone
Preferred Phone
EFL Coaching Mailing List *
In order to keep you informed about your coaching program, you must agree to have your preferred email address added to my clients-only mailing list. Your information will never be sold, rented, or in any way used by third parties.
This ADHD Life Mailing List *
You may wish to subscribe to my general mailing list. Simply choose 'Yes' below and your preferred email address will be added to the list.
Coaching Agreement *
I have reviewed and agree to the Coaching Agreement. I understand a copy will be sent to me upon payment and I agree to sign the signature form during our Intake Session.