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* 1. Mother's First and Last Name

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* 2. Father's First and Last Name

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* 3. Please provide 2 phone numbers and indicate whether cell or land line.

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* 4. Email address

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* 5. Young Adult's Name and Age/Grade

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* 6. Please describe the transition situation - the young adult is transitioning from and to what situations and settings.

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* 7. Referred by:

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* 8. Geographic area of home residence of young adult and also of parents:

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* 9. Has the young adult had neuropsychological or psychoeducational testing and if so, by whom in what city?

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* 10. What is your perception of your child’s learning needs? If she or he had an evaluation, what areas of strength and weaknesses did the evaluation pinpoint?

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* 11. Describe briefly any roadblock in your child’s development or school history in the areas of language, motor skills, reading/writing, math, personal regulation, social and emotional skills:

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* 12. Other services your child currently receives, for example, counseling, vision therapy, tutoring:

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* 13. Other services your child has received in the past, for example, counseling, vision therapy, tutoring:

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* 14. Physical/mental health, including recurring illnesses or conditions such as asthma, ear infections, concussions or speech problems:

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* 15. Languages other than English spoken in family:

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* 16. In the space below, please describe which of these five areas you believe your child needs support with: 1) gaps in academic skills, 2) different learning style, 3) personal regulation skills such as organization, follow through, time management, 4) practical skills - the “rules” of the new environment, 5) developing emotional resilience.

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* 17. Please describe the outcomes you would like your child to achieve by working with me.

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* 18. On a scale of 1 - 10, how ready and willing are you to facilitate your child's personal improvement.

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* 19. On a scale of 1-10, how eager for help is your child? Do you believe your child will have a positive response to educational and coaching support?

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* 20. Questions about business issues such as costs, scheduling, etc.

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