TEEN LIFE COACHING

1542 Kingsley Ave., Suite 136 Orange Park, FL 32073

605 St. John's Ave., Suite 102Palatka, FL 32177

904-214-3222 (office)904-621-9140 (fax)info@fsrcenter.com

www.FSRCenter.com

My Teen’s Life Coach is:______________________________

The Life Coach’s Number is:___________________________

Welcome to Our Life Coaching for Teens Program!We are so excited your teen is taking the first step towards having the life they really want! Most of us at some point feel we want things in our lives to be different, but don’t always know how to make the changes we need to or can’t do it on our own because we get stuck. We are looking forward to partnering with both you and your teen to help them make positive changes so they can reach their full potential.

The purpose of this packet is to provide you with some important information before we begin our journey. We hope to answer some questions you have and provide you with some insight as to how we will work together. In order for us to get a strong start, we are enclosing some paperwork for you to review, complete, and give back to us. Please complete it as soon as possible so we have it to discuss during our next meeting.

Below is a list of the items in this packet for you to . . . Review:

Coaching Expectations Benefits of Coaching

Review, complete, sign with your teen, and return: Life Coaching Agreement Notice of Privacy Practices for Counseling & Coaching Services Authorization for Release and Exchange of Information (print and complete separate

forms for each Parent/Guardian, Emergency Contact, and others you would like us to be in contact with).

Complete and return: Contact and General Information Life Success Scale (each Parent/Guardian should fill out separately) Tell Me About Your Teen

If you should have any questions, please feel free to e-mail our office or your life coach. Otherwise, we will discuss these items during our next session which we invite you to attend with your teen. We are so excited and honored to have been chosen by you to be your teen’s Coach! We are 100% dedicated to their success!

Sincerely,Christina M. St.Clair, LCSW, MCAP, SAPCEO, Family Services and Resource Center, Inc.

Coaching ExpectationsWhat You Can Expect ...Confidentiality: The nature of the Coaching relationship involves sharing personal and confidential information. There may be times when your Coach feels it is important for your teen to share issues with you and will encourage them to do so. It is always the goal to keep parents informed of the general Coaching progress. However, unless permission is granted, all conversations, Coaching sessions, and written communications will remain confidential between the Coach and your teen, except where prohibited by law.

Rewarding Action #1: Your teen will get to know themselves in new ways. Working with your Coach is a healthy way for them to grow. Most clients work with a Coach to accomplish several specific goals. Coaching is all about being and expressing your real and best self. So don't be surprised if they discover new parts of themselves or if they find their goals adjusting to reflect who they really are and who they want to be. This discovery process is natural, so there is no need for them or for you, as a parent, to put pressure on your teen to rush it, just realize it will likely happen. Accelerated personal growth is a benefit of being Coached.

Rewarding Action #2: Your teen should fully invest in this opportunity for accelerated growth and accomplishment. They should show up for Coaching sessions on time, prepared, and fully ready to problem solve, reflect, strategize, and celebrate. It is helpful for them to not be rushed to the session and take a few moments prior to slow down, clear their mind, and get focused. They should turn off all distractions in the environment such as TV, internet, music, and their cell phone if it’s not being used for our session. They need a quiet place where the only focus is our session, and others should be told not to disturb them as it is their time for Coaching. It is always a great idea to have a pen and paper handy for jotting down things during the session. They are more likely to remember and take action on things they write down. All Coaching materials should be kept together in a special notebook and folder just for their Coaching and bring them to each session.

Expect Your Coach To...Listen: Your Coach will listen for many things such as what motivates, energizes, and excites your teen, their beliefs and conclusions, what they’re saying in their self-talk, evidence of emotional pain that blocks action, self-doubt, growth they may not be giving themselves credit for, resources they have available but may not recognize, and much more. Your Coach will communicate with you as needed and will listen to you as well, but the main focus will be on your teen’s healthy goals which may or may not be exactly the same as your goals for them.

Question: Your Coach will ask your teen tough questions and may even ask you tough questions. Some questions may be difficult to answer or uncomfortable to share about, but remember the more you allow yourselves to be honest, to be challenged and stretched, the more progress will be made. This is not always an easy process and as a result, they may need a little space after sessions.

Have Integrity: Your Coach will abide by the International Federation of Coaching Code of Ethics.

Design: Your Coach assists your teen in defining their personal goals in alignment with their needs and values, assists them in creating strategies, discovering resources, and taking action confidently.

Facilitate Forward Action: A Coach does not provide Counseling or Therapy. Instead, a Coach makes requests, offers suggestions, advice, and opinions that may be helpful in facilitating ongoing forward momentum. Your Coach is an equal partner with your teen in designing their action plan.

Strengthen and Inspire: Your Coach will cheer your teen on and celebrate with them, help them to see their strengths, overcome self-doubt, and emotionally to dare to risk and change.

Stretch: Your Coach will help them to develop their goals, stretch towards their dreams, think bigger, go farther, be committed, grow, and achieve more than they’ve dared to imagine.

Develop Self-trust: Your Coach will assist them in seeing themselves as someone both of you can trust and depend on. Developing more confidence, knowing they can trust themselves, and reach out to others will make them stronger. Becoming dependent on your Coach is not the purpose of Coaching.

There Are So Many Amazing Benefits of Life Coaching!

Your Teen Can…Get Unstuck✔Move forward in their life✔Focus on getting healthier in every area✔Discover how to create positive life changes✔Take back control✔Find a new path and move towards it✔ Change their life for the better✔Design manageable next step actions✔Uncover sources of resistance to break free

Reach Their Goals and Live Their Dreams✔Find their unique purpose and passion✔Realize their authentic self, strengths, and gifts✔Become more intentional about reaching their goals✔Start to live their life on purpose✔Feel empowered to become who they’re meant to be✔ Clarify their goals and values✔Identify what they really want for their future✔Figure out and focus on their priorities✔Utilize valuable assessments tools to reveal

important characteristics about themselves

Manage Their Emotions✔Build their self-esteem and confidence✔Break free of anxiety and fear of the unknown✔Be motivated and feel empowered✔Gain tools and strategies to cope with life pressures✔ Create a more balanced life✔Reduce their stress and be less overwhelmed✔Increase their energy to deal with life problems✔Learn how to communicate their feelings to others

Develop Healthy Relationships✔Progress in their relationships✔Form stronger family bonds✔Achieve independence in a healthy way✔Improve communication and social skills✔Set healthy boundaries✔Date without losing themselves in the process✔ Control their behavior✔Stand up to and conquer peer pressure✔Make and keep good, supportive friends✔Let go of past hurts and resentments

✔ And so much more!

Life Coaching AgreementThank you for choosing Family Services and Resource Center for your Life Coaching needs! We look forward to guiding, supporting, and empowering you on your path to success!

This Service Agreement outlines the policies and practices for Coaching. Should you have any questions, feel free to discuss them with your Coach. From this point forward, in this agreement terms like “I” or “you” refer to the client, and parent/guardian(s), where applicable. Coaching strategies will be tailored to your unique needs. Your sessions will be conducted with the most compassionate methods possible regardless of age, race, cultural identity, ethnicity, gender, disability, religion, sexual orientation, marital, or socioeconomic status.

COOPERATION

It is assumed all parties will be in full cooperation with each other in regards to the agreed upon Coaching objectives. Neither party will withhold important information, which would benefit the Coaching process, nor will any party act in any manner that would interfere with facilitation of the Coaching goals in a timely manner. Coaching is most effective when all parties are open, honest, and straightforward in their communication. Therefore, expect your Coach to hold you accountable on your commitments in order to facilitate change.

THE COACHING PROCESS

Coaching typically includes weekly appointments for at least a number of months. Sessions will continue until you feel you have accomplished your personal goals. A minimum 3 month commitment to Coaching is required for best Coaching results. Sessions are typically 1-2 hours in duration. However, more frequent sessions and longer timeframes can be arranged.

At the end of each Coaching session, the client typically agrees to goals to work towards prior to the next session and an assignment to be completed before the next session in order to help increase success.

1.As a client, I understand and agree I am fully responsible for my wellbeing during my Coaching sessions, including my choices and decisions. I agree not to hold Family Services and Resource Center, my coach, or any company they are affiliated with, liable for any outcomes resulting directly or indirectly from the Coaching process.

2.I understand “Coaching” is a relationship I have with my Coach that is designed to facilitate the creation/ development of personal goals and to develop and carry out a strategy/plan for achieving those goals. I am aware I can choose to discontinue Coaching at any time.

3.I understand Coaching is a comprehensive process that may involve all areas of my life, including relationships, education, spiritual, health, work, finances, and recreation. I acknowledge deciding how to handle these issues and implement my choices is exclusively my responsibility.

4.I understand Coaching does not treat mental disorders as defined by the American Psychiatric Association. I understand Coaching is not a substitute for Counseling, Psychotherapy, Psychoanalysis, Psychiatry, or Substance Abuse Treatment. I will not use it in place of any form of Therapy. If I believe I may need Therapy in addition to Coaching, I will speak to my Coach about options.

5.I promise if I am currently in any form of Therapy, seeing a Psychiatrist, or otherwise under the care of a mental health professional or doctor, I have consulted with such persons regarding the advisability of working with a Coach and such persons are aware of my decision to proceed with the Coaching relationship. I am willing to sign a full Authorization for Release and Exchange of Information to these individuals so my Coach can openly communicate with them so I can achieve the best results.

6.I understand Coaching isn’t to be used in lieu of other professional advice. I’ll seek professional guidance for mental, legal, medical, financial, or other matters. All decisions in these areas are exclusively mine and I acknowledge my decisions and actions regarding them are my responsibility.

7. Coaching assumes each person in the relationship is guided by his or her values and beliefs.

8. I grant my Coach permission to keep a confidential record regarding my Coaching progress.

9.As a minor, I agree to sign a full Authorization for Release and Exchange of Information to my parent/ guardian(s). My Coach will include them in Coaching and share information with them as needed regarding my progress. If communication with one of my parents/guardians would hinder the Coaching process, I will speak to my Coach before signing an Authorization for Release and Exchange of Information to them. I understand information will be held as confidential unless I state otherwise, in writing, except as required by law.

Client’s Signature Printed Name Date

Parent/Guardian Signature(requiredforclientsunder18) Printed Name Date

Coach’s Signature Printed Name Date

ONE MORE WORD ABOUT CONFIDENTIALITY

Confidentiality and protection of intellectual property is mutually agreed to be protected by this contract of agreement. Therefore, both parties agree all data, information, and work completed during the course of Coaching will remain confidential. No information or materials will be shared with outside sources, on the internet, or other people regarding the work of either party, except with express written permission of both parties. Your identity and the nature of the sessions will be kept private from any third parties unless a written consent is provided.

However, your Coach may confer with another Coach or professional to discuss strategies to help you achieve your goals. If you choose not to provide written consent, your Coach may still seek out the advice of another professional without revealing your name or any identifying information. In case your Coach has an emergency, your Coach has established an emergency plan with other professionals to make sure you are notified and your needs are cared for. In which case, your information may be disclosed to them.

There are 3 exceptions to confidentiality:1. When disclosure is imminent to prevent self-harm or harm to others2. When a child, elder, or disabled person is in need of protection3. When legal demands require confidential material be released

MODIFICATIONS AND EVALUATIONS

Either party may modify this contract at any time it becomes apparent modification is needed. The client may terminate Coaching at any time.

The Coach agrees to advise and influence ideas and action. However, the client is always the final decision maker in the Coaching process. By signing below, I certify I have read this Life Coaching Agreement and agree to abide by all above policies and procedures. I also agree to hold my Life Coach and Family Services and Resource Center, Inc. harmless for any adverse situations created as a direct or indirect result of specific Coaching, advice, or referrals given. I acknowledge the receipt of a copy of this Agreement.

Client’sSignature PrintedName Date

Parent/GuardianSignature(requiredforclientsunder18) PrintedName Date

Coach’sSignature PrintedName Date

Acknowledgment of Receipt of Privacy Practices

I have received a copy of the Family Services and Resource Center, Inc. Privacy Policy Practices. I understand and agree to the conditions of such.

Client’s Signature Printed Name Date

Parent/Guardian Signature(requiredforclientsunder18) Printed Name Date

Client Contact and General Information Please complete the following information to the best of your knowledge regarding your teen

Client Name (first, middle, last):

Demographics:Father’s (Guardian’s) Name: Date of Birth:

Address: City, State, Zip:

Father’s Cell#: ( ) Home#: ( _) _ Work# :( ) ext:

Preferred # to be reached at: Primary Email:

Mother’s (Guardian’s) Name: Date of Birth:

Address: City, State, Zip:

Mother’s Cell#: ( ) Home#: ( ) Work# :( ) ___ _ext:

Preferred # to be reached at: Primary Email:

Stepfather’s/ Mother’s S/O Name: Date of Birth:

Address: City, State, Zip:

Stepfather’s Cell#: ( ) Home#: ( ) Work# :( _) ext:

Preferred # to be reached at: Primary Email:

Stepmother’s/ Father’s S/O Name: Date of Birth:

Address: City, State, Zip:

Stepmother’s Cell#: ( ) ____ Home#: ( _) _ Work# :( _) _ext:

Preferred # to be reached at: _ Primary Email:

Emergency Contact :Emergency Contact (Other than Parent/ Guardian): Relationship to You:

Address: _ City, State, Zip:

Cell#: ( ) Home#: ( ) Work#:( ) ext:

Primary Email:

Teen’s Health: Primary Care Physician’s Name: _ Date of last physical: Address: _ __City, State, Zip: Office#: ( ) ext: Cell#: ( ) Email: Medical Issues (including Asthma, Pregnancy, Diabetes, etc): Current treatment for any medical issues: Allergies: All medications (prescribed and nonprescription) taking and reason for taking each:

Any alternative medicine (past or present) such as Chiropractic, Essential Oils, Supplements, Yoga, etc?

Does your teen have any history of drug, alcohol, or tobacco use? Explain:

Describe teen’s exercise habits: Describe teen’s sleep habits: Describe teen’s eating habits: To your knowledge, is your teen sexually active (include and specify use of porn, sexting, hooking up, etc)?

Other health related concerns: Mental Health Issues (Past or Present) - Depression, Anxiety, ADHD, Self-harm, Eating Disorder, Anger, Suicide or Homicide Thoughts/ Attempts, Hospitalizations, etc. Explain each:

Any traumatic or significant events that have affected them emotionally:

Have they seen a Therapist/ Counselor (past or present)? Dates seen: Therapist/ Counselor’s Name: If current, do they approve of teen participating in Coaching? Explain: Reason seeing (saw) Therapist/ Counselor: Address: _City, State, Zip: Office #: ( ) ext: Cell#: ( _) _Email: Have they seen a Psychiatrist (past or present)? Dates seen: Psychiatrist’s Name: If current, do they approve of your teen participating in Coaching? Reason seeing (saw) Psychiatrist: Address: _ __ City, State, Zip: Office#: ( ) __ext: _ Cell#: ( _) ___ _ Email:

Teen’s Education/Work: Were (are) there any classes or school subjects that were (are) hard or especially easy for them? Explain:

Were (are) they in any special education, gifted, or accelerated classes? Which one(s)?

How have they done in school and/or work (i.e. grades, working to potential, behavior, attendance, relationships with authority, work ethic, etc)?

Any significant school or employment history, events, or concerns?

Leisure Activities : Leisure activities, hobbies, clubs, church, sports involvement:

Estimate average hours spent on technology weekly: How many of those are for School /Work: Estimate hours spent on media weekly (specify TV, Texting, Gaming, etc): Describe their social life (i.e. friends, dating, healthy/ unhealthy relationships):

Do they drink alcohol or use drugs (prescription or street) recreationally (Past or Present)? If so, explain in as much detail as you are aware of:

Do they have any addictions or addictive tendencies? Explain:

Strengths and Weaknesses:What do you think their greatest strengths are?

What do you think their greatest weaknesses or areas or improvement are?

Signature: Printed Name: Date: Signature indicates that the information above is accurate to the best of your knowledge

How Did You Score?10 - 25 = Crisis Level25 - 50 = Unhealthy Living Level 50 - 75 = Healthy Living Level 75 - 100 = Optimal Living Level

Life Success Scale

Your Name: Your Teen’s Name: Today’s Date:

Now let’s get really honest! Take an intense look at your teen’s life. Score them (from your perspective) usingthe following scale. From 1-10 evaluate how successful they currently are in the major areas of their life.

1 = Panic 3 = Weak 5 = Moderate 7 = Low Strength 9 = High Strength2 = Extremely Weak 4 = Low Moderate 6 = High Moderate 8 = Strength 10 = Peak

Physical Health (nutrition, exercise, weight, sleeping, self-care, managing stress)

Emotional Control and Health (self-esteem, self-control, confidence, managing mood)

Spiritual Health (consistently living within their belief/value system, character, integrity, ethics)

Financial Responsibility (money management, savings, debt, credit cards)

School and Work (grades, assignments, attendance, work ethic, relationships) _____

Social Support and Friendships (asking for help, not isolating when life is hard)

Family and Closest Relationships (healthy relationships, strong connections, dependable)

Time, Organization, and Schedule (procrastination, planning, goal directed, follow through)

Learning and Personal Growth (continuing to learn new things and grow as a person)

Recreation, Relaxation, and Taking Time for Fun (enjoying the journey, taking down time)

Life Success Scale Total Score =

Top 3 Areas I Would Like My Teen to Focus on in Coaching (Explain Your Choices)

Things I Need to Change About Myself/ My Life to Help My Teen Succeed:

Tell Us About Your Teen Your Teen’s Name:

Reason you are seeking a Coach at this point in time for your teen:

Primary known goals you would like your teen to address in Coaching:

How motivated do you think they are to make changes? Include what you believe motivates them:

Projected timeframe you would like your teen to accomplish their goals:

Teen’s available time (days/hours) for Coaching sessions:

Parents available time (days/hours) in case it is determined it would be beneficial for you to be involved in any Coaching sessions:

Any other background information your Coach needs to know or you would like your Coach to know:

_Parent/ Guardian’s Signature Printed Name Date