Parent Questionnaire "*" indicates required fields Please answer the following questions as thoroughly and as honestly as possible. All information disclosed will remain confidential and I will approach your concerns in a subtle, professional manner. In order to turn your son/daughter into a responsible, confident, risk-taking young adult I need to first understand where they are at this point. Thank you.Child Name*AgeGradeCell PhoneEmail Parent's Names (Mom)*Cell PhoneEmail Parent's Name (Dad):*Cell PhoneEmail Emergency Contact Name (if parents can’t be reached)*Cell Phone*Section 1: Family Dynamic & Parent ExpectationsWhat is the makeup of your household (married/divorced, siblings, others)?Describe the family dynamic. How are the relationships between your child and other members of the household?Who is part of your child’s support system (who is in their lives)?Rate your child’s behavior at home on a scale of 1-10. (Poor) 1 2 3 4 (Neutral) 6 7 8 9 10 (Commendable) Explain your selectionRate your child's work ethic on a scale of 1-10. (Minimal) 1 2 3 4 (Neutral) 6 7 8 9 10 (Maximal) Explain your selectionHow would you describe your parenting style? Please rate the level of structure/rule enforcement. (Enabling) 1 2 3 4 (Neutral) 6 7 8 9 10 (Too tough/strict) Explain your selectionWhat is the most important thing I should know about your child?What are your greatest concerns?Section 2: School/Social Dynamic & ActivitiesRate your child’s behavior at school on a scale of 0-10. (Poor) 1 2 3 4 (Neutral) 6 7 8 9 10 (Commendable) Explain your selectionHow are their grades and relationships with their teachers?How are their relationships with their peers? What are their friends like?What sports/physical activities does your child engage in? What are their strengths and weaknesses?Section 3: Health & PersonalityHow would you describe your child’s overall physical health?How would you describe your child’s overall emotional healthRate your child's self-esteem on a scale of 0-10. (Low) 1 2 3 4 (Neutral) 6 7 8 9 10 (High) Explain your selectionDoes your child have any injuries/medical conditions and/or is prescribed medication at this time?Are there any counseling services or relevant medications being prescribed at this time?What is your child passionate about?What would you like your child to gain from this program?Is there anything else I should know about your child?CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ SHOP Go To Shop Basketball Training Learn More Fitness Trainer Learn More Youth Mentor Learn More Interested in working with Mike? Schedule a call Contact
