Intake form

Name *

Email address *

What is your child's age?

What type of workshops are you interested in?

Please select at least one option.

Emotional regulation

Coping skills

Mindfulness

Yoga and breathwork

Art and crafts

Dance and movement

What are your primary goals for your child in attending these workshops?

Do you have any specific concerns or challenges you would like to address?

What is your relationship to the child?

What is your preferred method of communication?

Please select at least one option.

Email

Phone

Text message

What is your availability for workshops?

Please select at least one option.

Weekdays

Weekends

Evenings

Would you like to receive coaching services for yourself?

If yes, what specific areas do you seek coaching for?

Which service or services are you interested in?

Please select at least one option.

Emotional regulation workshops

Mindful movement classes

Coaching for moms

Additional questions or comments

Empower Mind Body Studios/Empowered Kids