Parent Questionnaire

Parent(s), this is the first step in our program selection process. Upon review we will contact you via a phone call to discuss your son’s eligibility to enter our coaching program. Please fill out this questionnaire as accurately as possible. Thank you!

Coaching Youth Contact Form

Your full name (parent or guardian)

Email Address

Phone Number

Your son’s name

Your son’s age

Your son’s current school grade

Rate your son's: Self Esteem [Select From Dropdown]

Rate your son's: Confidence [Select From Dropdown]

Rate your son's: Overall Happiness [Select From Dropdown]

Rate your son's: School work [Select From Dropdown]

Rate your son's: Social life [Select From Dropdown]

Rate your son's: Fitness [Select From Dropdown]

Rate your son's: Nutrition [Select From Dropdown]

Rate your son's: Hygiene[Select From Dropdown]

Rate your son's: Sleep [Select From Dropdown]

Rate your son's: Family life [Select From Dropdown]

Rate your son's: Self Worth [Select From Dropdown]

Rate your son's: Responsible [Select From Dropdown]

Rate your son's: Maturity level for age [Select From Dropdown]

If your son plays Xbox or other video type devices, how many hours a day does he play?

What do you think is the biggest factor affecting your son negatively right now?

Does your son experience high levels of anxiety? Does your son experience high levels of anxiety? Yes No

Does your son use drugs of any type? Does your son use drugs of any type? Yes No

Does your son openly discuss his concerns and problems with you? Does your son openly discuss his concerns and problems with you? Yes No

Is there a negative influence in your son’s life that needs to be removed? Is there a negative influence in your son’s life that needs to be removed? Yes No

Does your son have a current mentor or someone he looks up to? Does your son have a current mentor or someone he looks up to? Yes No

Who is this person in relationship to him?

3 + 5 =

Note: All information on this questionnaire is confidential and will not be shared to a 3rd party.

Thank you for considering Tier 1 Performance Coaching !

Give us 48 hours to review your specific needs and goals.