Family Advocacy & Consultation
Welcome,
Complete this form to request or ask questions about family consultations and advocacy.
After submitting the form, we'll ask you to schedule a 15-minute time slot for a discovery call with our family coordinator. It is not necessary for the student to be part of this call.
Please note we do currently have coaching availability in our Walnut Creek and Oakland offices. Space is limited.
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)
Interested In
1:1 Coaching
Advocacy
Consultation
Workshops
Custom Workshops
Study Space Makeover
Speaking Engagements
Mobile Phone (Parent 1)
Address
City
Address Line 2
State
Other Parent Information
Zip
Would you like your intake meeting to be via phone or Zoom?
Phone
Zoom
Student
First Name
Last Name
School
Grade (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, College)
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)
Homework Load per Day
Weekly Coaching Availability (if applicable)
Walnut Creek
Oakland
Online
Extracurricular Activities
School Accommodations? (ie IEP, 504, learning planning)
Yes
Evaluations? (e.g. School Testing, Neuropsychological Reports)
Yes
External Services (Content Tutor, Counselor etc.)
Areas of Concern
Referred By
Preferred Pronouns
Remove
Add Fields for Additional Student
Submit
