Your Full Name

Your Email Address

You are the: You are the: Mother (or step) Father (or step) Other relation

Your Son/Daughter's Full Name

Their Age: Their Age: Younger than 10 10 - 12 13 - 14 15 Older than 15

What areas is your son/daughter struggling with? What areas is your son/daughter struggling with? Their social life In academics Emotions and self esteem Other

What changes would you like to see in them?

What types of things have you already tried to effect a change?

How do you feel a growth mindset will benefit your child?

Is there anything else you'd like to share about your son/daughter?

How did you find out about Bridge of Empowerment coaching?