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Intake Questionnaire - Teen/Young Adult

For Teens/Young Adults in 1:1 Coaching Containers

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Question 1 of 24

Client Name(s):(List all participating family members)

Question 2 of 24

Best Contact Info:
  • Email:
  • Phone:

Question 3 of 24

Role

A

Parent

B

Teen

C

Young Adult

Question 4 of 24

Ages:(Teen / Young Adult)

Question 5 of 24

Grade / School / Program:

Question 6 of 24

School Environment:
  • Public / Private / Homeschool / College / Other
  • How would you describe the school culture & support system?

Question 7 of 24

What is the biggest goal you want to focus on in coaching?

(Select all that apply)
A

Parent-Teen Relationships

B

Confidence / Social Life

C

Executive Function / Organization

D

Purpose / Life Direction

E

Motivation / Follow-Through

F

School Stress / Performance

G

Emotional Regulation / Overwhelm

H

Big Transition (describe below)

I

Other:

Question 8 of 24

If you selected Big Transition or Other in the previous question, please elaborate below.

Question 9 of 24

In your own words — what are the main challenges or patterns you want support with?

Question 10 of 24

What have you already tried?(Programs, strategies, professionals, approaches — and what did or didn’t work)

Question 11 of 24

Is there any relevant family history/context you think I should know?(Transitions, trauma, learning differences, diagnosis, major stressors)

Question 12 of 24

How do you tend to show up when you’re stressed?(Behavior, feelings, thoughts, body sensations)

Question 13 of 24

As a teen: How do your parents show up when you’re stressed?

Question 14 of 24

What beliefs do you hold about parents having expectations?

Question 15 of 24

What’s working well right now?(Successes, resilience, what you appreciate)

Question 16 of 24

What are your biggest strengths?

Question 17 of 24

What are your biggest growth areas — things you’d like to improve?

Question 18 of 24

Describe your dream day as a family.(optional)

Question 19 of 24

What’s your biggest wish for coaching?— What would success look like in 3 months? 6 months?

Question 20 of 24

What would it feel like if nothing changed?(Helps you understand urgency & motivation)

Question 21 of 24

How committed do you feel to doing this work?Scale: 0 (not at all) — 10 (fully committed)Why did you choose that number?

Question 22 of 24

Who else in the home is involved in coaching / support?(Siblings, other caregivers, therapists, teachers — if applicable)

Question 23 of 24

Daily Routine Snapshot
  • What time do you wake up and go to sleep?
  • Typical homework / family time?
  • Anything else? Extracurriculars

Question 24 of 24

Values Inventory

• What matters most in your family right now?Connection / Independence / Achievement / Peace / Growth / Fun / Order / Other: _______

Confirm and Submit