Student Success Coach Intake

Please complete this short intake form before requesting your free 30-minute consultation. This will help us better understand the student’s needs, goals, and how Student Success Coaching can best support them.

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Student Full Name *

Parent/Guardian Name *

Best Email *

Best Phone Number

Student Grade Level *— Select Choice —8th9th10th11th12thCollegeOther

Student Age

School Name *

What support is the student primarily needing right now? *

• Test anxiety
• Academic stress
• Confidence
• Motivation
• College planning
• Life direction
• Accountability
• Faith-based encouragement
• Other

What Student like

What are the biggest challenges the student is currently facing? *

Does the student struggle with stress or anxiety? *

• Yes, often
• Sometimes
• Rarely
• Not sure

Would you like faith-based encouragement included if appropriate? *

• Yes
• No
• I am open to it

What type of support are you most interested in? *

• One-time consultation
• Ongoing coaching
• Not sure yet

What days and times usually work best for a consultation? *

Is there anything else you would like us to know before the consultation? *

Please confirm the following: *

• I understand this is coaching and mentoring support only and not therapy, counseling, medical advice, or crisis care.

Request Consultation