Teen Intake Form

First name

Last name

Age

School/Grade

About You

What activities do you enjoy?

What qualities are you proud to share with others? (e.g. kindness, intelligence)

What kind of music do you listen to? Favorite music artists?

How do you like to unwind and relax?

What’s been hard or stressful for you lately?

What’s been going okay or better than expected?

When do you feel most like yourself?

Is there something about yourself that you wish people understood better?

What’s something you’ve been struggling with that you'd like to figure out?

How much time do you spend on social media?

Have you ever worked with a coach or therapist before? If so, how was it?

What kind of support do you want from me? (Pick all that feel right)

Someone to talk to who doesn’t judge

Help figuring out why I do what I do

Tools to help with confidence or decision-making

A safe space to be real

Something else

If you chose "something else", please explain

Anything else you want me to know before we start?