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Intake Form

Welcome

Thank you for trusting me with your journey. Please complete what feels comfortable. This form helps guide our first conversation and keeps the process simple

Basic Information

Full Name
Child's Name

What brings you here today?

Current Challenges - check all that apply

Emotional Check-In & Support Needs

This helps us start with compassion and clarity.
How have you been feeling lately? - check all that apply
Overall emotional wellbeing this week
Check one number: 1 = very difficult, 10 = doing well
Advocacy & Support
Check one number: 1 = very difficult, 10 = doing well

Goals, Commitment & Acknowledgment

Your voice matters. Your goals guide the coaching plan.
Examples: feel more confident, reduce stress, learn to advocate, feel supported, find resources, create a simple plan.
Are you ready to commit to coaching support?

Acknowledgment

By completing this form, I understand that Rise & Shine Life Coaching is supportive coaching based on lived experience. It is not therapy, medical care, psychological treatment, or crisis intervention.
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About This Space

- Speak freely without fear of judgment.

- Process emotions at your own pace.

- Build confidence in your voice and advocacy.

- Prepare for IEP meetings, appointments, and difficult conversations.

- Feel supported between sessions.

Coaching Format

Rise & Shine Life Coaching does not diagnose, treat, or cure any condition. It is not a substitute for licensed
mental health care or medical care. If you are in crisis, call 988, contact a licensed mental health professional, or
go to the nearest emergency room.

Important Disclaimer

Sessions are held virtually by Zoom or phone. Coaching includes active listening, reflection, lived experience,
gentle guidance, and support with advocacy conversations. Messaging support is available between sessions, with
responses within 24 hours during business days.

Boundaries

Please provide at least 24 hours notice to cancel or reschedule. Sessions start and end on time to honor both of
our commitments.