Girl Empowerment Inquiry - Raising a Powerful Girl

Parent Name *

First

Last

Girls Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Girls Age and Grade Level *

How did you hear about me? *

Please tell us a little bit about her extra cirricular activities she enjoys (dance, riding, art, voluneer work etc) *

Please tell us of any challanges she has faced or is facing ( Health issues, Mental Health Issues, Bullying, Cut from a team etc) *

Do you have any specific concerns or challanges with your daughter? *

What is your hope as a result of this Experience? *

Any other comments etc? *

When are you hoping to schedule a session? *