Intake Form

Tell me a bit of information about the child and the family to help determine if this coaching program is a great fit for you!

Parent Names (one or both)

Name of Children

Address

City

State

Telephone

More Family Details

Birthdates (please list of each child)

Emergency Contact Name

Emerg. Contact Phone

Emerg. Contact Email

Parent Occupations

Family Statistics (children, married/unmarried, etc)

Family Hobbies and Additional Interests

School Name, Phone Number, and Email

Intentions and Experience

What is your intention for signing up for this retreat? Have you done something like this before?

What do you hope to gain from this experience?

Where would you and your family like more clarity in your life?

Parent Personal Growth

Please describe any current practice or belief that is related to your personal growth.

Please list any training or healing modalities, that you have participated in that have guided you on your personal growth journey.

What are your hobbies and interests?

Children Growth and Development

Please describe your children’s growth and development up to this point in their lives.

Child(ren) Health History

Please tell us about your children's physical health (list any major illnesses, surgeries, any pervious injurious or physical conditions that may impact your well-being)

List any allergies or medications

Has your child(ren) ever been diagnosed with a mental health disorder? Past or Present?

Does your child have current psychotherapy, counseling or psychiatric treatment? Please describe:

More About the Children

As parents, how would you best describe your children? (please list each individually)

What are their personal strengths as seen through your eyes?

What (if any) challenges are they experiencing through your eyes? (please list each individually)

What are your children’s hobbies and interests?

Relationships

Please share with us your relationship as parents:

Please share with us your relationship with your kids:

Please share with us the relationship your kids have together:

Client Consent

attest that my child(ren) is in sound physical and mental health to participate in Jake Roussos Coaching. I understand that it is my responsibility to communicate all questions and concerns to Jake as appropriate. The relationship of this coaching experience will be held in confidential boundaries, unless the safety of your child(ren) is a concern.