Parent Intake Form

Parent/Guardian #1 (Primary Contact)

Parent/Guardian Full Name*

Relationship to Teen*

Parent Phone #*

Parent Email*

Parent Address*

Parent/Guardian #2

Parent/Guardian Full Name*

Relationship to Teen*

Parent Phone #*

Parent Email

Parent Address

Teen's Full Name*

Birthday

Month

Day

Year

Emergency Contact Name*

Additional Emergency Contact Name

Additional Emergency Contact Phone #

Custody & Consent*

Parents are married

Parents are divorced or separated

Other

Who holds legal decision-making rights for this child?*

Both parents (joint legal custody)

One parent only (sole legal custody – please attach documentation)

Not sure- I will get back to you

Has the other parent given consent for this teen to participate in coaching?*

Yes

No

Not yet, but I will obtain it

Not required

Anything else I should be aware of regarding custody, communication, or parental involvement?

File upload for any necessary documents

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