Summer Coaching
Welcome,
Complete this intake form to provide information about your student including summer coaching goals. Before you do please review information about the summer coaching process, including pricing and commitment to a 4 session package:
https://sos4students.com/wp/summer-coaching
For sessions with Dayna, Marco, Raina, or Vivian- the 4 session package is $740
For sessions with Beth- the 4 session package is $900
Additional session can be purchased.
After submitting the form, within one business day, you will be able to schedule sessions through our online platform Teachworks. (Existing coaching clients can log in using their existing credentials)
Regards,
Beth Samuelson
Director, SOS4Students
Parent
First Names (Parent 1 & Parent 2)
Last Name (Parent 1 & Parent 2 unless same)
Email (Parent 1)
Email (Parent 2)
Mobile Phone (Parent 1)
Address
City
Address Line 2
State
Other Parent Information
Zip
Credit Card Details
You will be charged for a four-session package.
Student
First Name
Referred By
Male, Female, Non-binary, Other
Preferred Pronouns
Last Name
School
Grade (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, College)
Areas of Concern
Challenging Areas
Task initiation
Attention (In class and/or at home)
Planning (may include planner use and/or prioritizing work)
Managing routines like medications or getting out of bed and out the door
Materials organization
Missing/make up work
Note taking
Procrastination
Test preparation
Self-advocacy
Time management (including morning and afternoon routines and tracking work)
Working more independently
Writing/organization for essays
Emotional regulation
Keeping healthy habits
Adaptability to new environment
Effective decision-making
Self-discipline
Prioritization
Reading and listening comprehension
Attending lectures (for college students)
Which Summer School Classes (if any)
Coaching Goals (2-3)
Strengths (academic, social, or otherwise)
Which Subjects are Strengths and Challenges?
Strengths/Challenges for Assignments. Groups? Visual? Essays?
Grades?
How frequently do you check grades?
Usual Bedtime?
Do you wakeup student in the morning?
How often late to school?
Phone
Electronic Device
Social Media
Video Games
Any difficulties with phone, electronic device, social media, video games?
House rules for phone and computer?
Homework Location
Broken Record Conversation
Circumstances or recent events that help us understand needs?
Learning Differences
Yes
School Accommodations? (ie IEP, 504, learning planning)
External Services (Content Tutor, Counselor etc.)
Yes
Availability Locations
Walnut Creek
Oakland
Online
Coaching Availability
Select
Beth
Other
Coach Requests
Remove
Add Fields for Additional Student
Submit
