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Cenacle Scholar Institute
Scholar Coaching Registration Form
Preferred Scholar Coach (Optional)
How soon would you like to begin Coaching
What inspired you to seek support for your scholar from Cenacle Institute?
Academic Support
Social & Emotional Support
21st Century Skills Building
Other
Throughout the coaching process, we will discuss and fine-tune the goals you have for your Scholar. Please share both general and specific goals you would like to set.
Student's First Name
Student's Last Name
Student's Email
Student's Birthdate
Student's Grade Level
Parent/Guardian #1~FULL NAME
Parent/Guardian #1~Email
Parent/Guardian #1~Phone
Parent/Guardian #2~FULL NAME
Parent/Guardian #2~Email
Parent/Guardian #2~Phone
What are the best ways to contact you?
Phone Call
Text Message
Email
Other
How would you rate your scholar's overall mood and happiness level on a scale of 1 to 5?
1 (worst)
2
3
4
5 (best)
Are there any specific challenges the scholar demonstrates or has brought to your awareness?
List any extracurricular activities or hobbies that she/he finds enjoyable and fulfilling?
Does the scholar experience any difficulties in managing their emotions or dealing with stress? If so, can you provide some examples?
Is there anything else you would like to share?
What are your/your child's favorite school subject(s)?
Mathematics
Sciences
Reading & Writing (ELA)
Social Studies/History
Specials (i.e. music, art, tech)
Other
What academic areas would you like the coach to focus on during your coaching sessions?
Mathematics
Sciences
Reading & Writing (ELA)
Social Studies/History
Specials (i.e. music, art, tech)
Other
Does your child have an IEP?
Yes
No
Currently being evaluated for services
Previously but had child removed
Other
***If you answered yes above*** Are you open to sharing the IEP with your coach to better assist the student in the coaching process?
Yes
No
Maybe
Other
Provide any further information
Submit
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